Georgia Advanced Directive Page 18
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29(2) BACK-UP HEALTH CARE AGENT
[This section is optional. PART ONE will be effective even if this section is
left blank.]
If my health care agent cannot be contacted in a reasonable time period and
cannot be located with reasonable efforts or for any reason my health care
agent is unavailable or unable or unwilling to act as my health care agent,
then I select the following, each to act successively in the order named, as
my back-up health care agent(s):
First Back–up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers: ________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address: ___________________________________________________
Second Back-up Agent
Name: ___________________________________________________________
Address: _________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone Numbers:________________________________________________
_________________________________________________________________
(Home, Work, and Mobile/Cell)
E-Mail Address:____________________________________________________
Page 4 of 15
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Parent category: Medical