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POLST Download


This downloadable form is meant to serve as a master copy to be used to print bulk quantities (or single copies) of the form. It should be printed on 8-1/2" x 11" green card stock, front and back. For the card stock, you can use Astrobrights terra green (smooth finish), 65 lbs. (#22781), or an equivalent.

If you are a patient and want a POLST form for your own use or for a loved one, ask your physician or your physician's office for the form. If your physician does not have the forms in stock, they can order them in bulk by calling toll-free, 1 (800) 237-3329, or by contacting Justin Dale at jod@wsma.org.

The POLST form was revised in 2011 (the new version is marked "Revised 2/2011"). Previous versions of the form will continue to be honored. Please see note on the revision directly below.

Important message on revision:
If you have received, or downloaded, the POLST form marked "Revised 12/2010," please destroy/recycle your copies. All other versions are still valid.

Download the POLST form

(The POLST download is in [PDF] format and requires the use of Acrobat Reader. To download a FREE copy of Reader, please click on the Adobe icon)

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If you have problems with the download, or have questions regarding the printing/distribution of the form, please contact Graham Short at 1 (800) 552-0612, or email gfs@wsma.org.

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