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

Health Care Proxy Form Page 3

Limitations_________________________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not

be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized

by law, to consent to a donation on your behalf.

Signature ________________________________________________________________________________________

Date ____________________________________________________________________________________________

Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)

I declare that the person who signed this document is personally known to me and appears to be of sound mind and

acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my

presence.

Witness 1: _______________________________________________________________________________________

Address _________________________________________________________________________________________

Witness 2: _______________________________________________________________________________________

Address _________________________________________________________________________________________

Health Care Proxy Form Page 3