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Power of Attorney
- Advance Health Care Directive
Please Complete All Applicable
Sections
Select County:
Your Name:
Address:
City:
State:
Zip:
Phone:
Email:
Date of
Birth:
U.S. Citizen? Yes
No
Other Names:
Are you known by any other names.
Gender:
Male
Female
Name of
Spouse:
Provide the Full name of your spouse.
v
Power of Attorney Agent
My agent
I designate the following individual
as my agent to make health-care decisions for me
Address:
Alternate agent:
Agent address:
health-care
decisions:
My agent is authorized to make
all health-care decisions for me, including decisions to provide, withhold,
or withdraw artificial nutrition and hydration, and all other forms of
health care to keep me alive, except as I state here
m
Instructions for Health
Care
END-OF-LIFE
DECISIONS:
Prolong
Life Do Not Prolong
Life
RELIEF
FROM PAIN:
Except as I state in the following
space, I direct that treatment for alleviation of pain or discomfort be
provided at all times, even if it hastens my death:
Other Wishes:
Primary Physician:
Start
Power of Attorney effective date
Terminate
h
Optional Items
Describe Other Provisions desired:
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