Combined Living Will And Health Care Power Of Attorney (Page 4 of 5) in pdf

IV.

FURTHER COMMENTS

I also note the following:

_______________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________

APPOINTMENT OF HEALTH CARE AGENT

I appoint the following named individual as my health care agent:

________________________________________________________________________________________________

NAME / RELATIONSHIP

__________________________________________________________________________________________________

ADDRESS

TELEPHONE NUMBER:

Home

___________________________________

Work

___________________________________

Cell

___________________________________

E-MAIL ______________________________________________________________________________________

IF I DO NOT NAME A HEALTH CARE AGENT, I UNDERSTAND THAT HEALTH CARE PROVIDERS WILL ASK MY

FAMILY OR SOME ADULT WHO KNOWS MY PREFERENCES AND VALUES TO DETERMINE MY WISHES FOR

TREATMENT.

If the person I named above as health care agent is not readily available, I appoint the person or persons

named below to serve in the order listed.

FIRST ALTERNATE HEALTH CARE AGENT

________________________________________________________________________________________________

NAME / RELATIONSHIP

__________________________________________________________________________________________________

ADDRESS

TELEPHONE NUMBER:

Home

___________________________________

Work

___________________________________

Cell

___________________________________

E-MAIL ______________________________________________________________________________________

Page 4

Combined Living Will And Health Care Power Of Attorney Page 4