Vermont Advance Directive For Health Care Page 3
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8Vermont Advance Directive for Health Care
YOuR NAME ________________________________________________________________ DATE OF BIRTH ________________ DATE __________________________
ADDRESS ____________________________________________________________________________________________________________________________________
CITY _______________________________________________________________________ STATE _______________________ zIP ____________________________
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Your health care agent can make health care decisions for you when you are unable or
unwilling to make decisions for yourself. You should pick someone that you trust, who
understands your wishes and agrees to act as your agent.
I appoint this person to be my health care AGENT:
________________________________________________________________________________________________________________________
NAME
ADDRESS ____________________________________________________________________________________________________________________________________
HOME PHONE ________________________________________________________ wORk PHONE _________________________________________________________
CELL PHONE _________________________________________________________ EMAIL ________________________________________________________________
(If you appoint co-agents, list them above or on a separate sheet of paper)
If this agent is unavailable, unwilling or unable to act as my agent, I appoint this person as my
alternate agent:
NAME ________________________________________________________________________________________________________________________
ADDRESS: ____________________________________________________________________________________________________________________________________
HOME PHONE ________________________________________________________ wORk PHONE _________________________________________________________
CELL PHONE __________________________________________________________ EMAIL _________________________________________________________________
Others who can be consulted about medical decisions on my behalf include:
Primary care provider(s):
NAME _____________________________________________________________________________________________ PHONE _________________________________
ADDRESS ____________________________________________________________________________________________________________________________________
NAME _____________________________________________________________________________________________ PHONE _________________________________
ADDRESS ____________________________________________________________________________________________________________________________________
(PART ONE CONTINuED NExT PAGE)
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