Durable Health Care Power Of Attorney (Page 5 of 5) in pdf

Durable Health Care Power Of Attorney Page 5

OPTIONAL:

STATEMENT THAT YOU HAVE DISCUSSED YOUR HEALTH CARE CHOICES

FOR THE FUTURE WITH YOUR PHYSICIAN

NOTE: Before deciding what health care you want for yourself, you may wish to ask your physician

questions regarding treatment alternatives. This statement from your physician is not required by Arizona

law. If you do speak with your physician, it is a good idea to have him or her complete this section. Ask

your doctor to keep a copy of this form with your medical records.

On this date I reviewed this document with the Principal and discussed any questions regarding the

probable medical consequences of the treatment choices provided above. I agree to comply with the

provisions of this directive, and I will comply with the health care decisions made by the representative

unless a decision violates my conscience. In such case I will promptly disclose my unwillingness to

comply and will transfer or try to transfer patient care to another provider who is willing to act in

accordance with the representative's direction.

Doctor Name (printed): _________________________________________________________________

Signature: _____________________________________________ Date: _________________________

Address: ____________________________________________________________________________

DISCLAIMER: The law allows you to complete advance directives without the assistance of legal counsel. America Living

Will Registry provides these advance directive forms as a service to you and does not take responsibility for the manner in which

you complete them. If you have any questions about any part of these advance directive forms, be sure to consult an attorney

before you sign them.

America Living Will Registry, LLC, 2814 Beach Boulevard South, St. Petersburg, FL 33707

1-866-305-ALWR

web site:

e-mail:

Durable Health Care Power Of Attorney Page 5