Health Care Proxy Form (Page 2 of 3) in pdf

HEALTH CARE PROXY

(

___________________________________________________________________________________

1) I,

hereby appoint

____________________________________________________________________________________________

(name, home address and telephone number)

__________________________________________________________________________________________________________

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional Instructions: I direct my agent to make any and all health care decisions in accord with my wishes and

limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary).

________________________________________________________________________________________

(Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes), you agent will not be

allowed to make decisions about artificial nutrition and hydration. See instructions on reverse for samples of language

you could use).

Name of substitute of fill-in agent if the person I appoint is unable, unwilling, or unavailable to act as my health

(3)

care agent.

________________________________________________________________________________________________________

(name, home address and telephone number)

________________________________________________________________________________________________________

(4)

Unless I revoke it, this proxy shall remain in effect indefinitely or until the date or conditions stated below. This

proxy shall expire (specify date or conditions, if desired):

________________________________________________________________________________________________________

(5) Name (please print)_____________________________________________________________________

______________________________________________________________________________

Signature

______________________________________________________________________________

Address

_________________________________________________________________________________

Date

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)

Any needed organs and/or tissues

The following organs and/or tissues______________________________________________________

_____________________________________________________________________________________

Health Care Proxy Form Page 2