Durable Health Care Power Of Attorney Questionnaire Template Page 2
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Decisions You Expressly Do Not Authorize Your Representative to Make for You (Optional. Describe or write “not
applicable”):
Your Desires Regarding Autopsy (Optional. Under Arizona law, an autopsy is not required unless the county
medical examiner, the county attorney, or a superior court judge orders it to be performed. Initial one of the
following choices):
________
Upon my death I DO NOT consent to (want) an autopsy.
________
Upon my death I DO consent to (want) an autopsy.
________
My representative may give or refuse consent for an autopsy.
Your Specific Desires About Organ Donation (“anatomical gift”) (Optional. Under Arizona law, you may donate all or
part of your body. If you do not make a choice, your representative or family can make the decision when you
die. You may indicate which organs or tissues you want to donate and where you want them donated. Initial by
A, B, or C below. If you select C, continue with your choices):
________
A. I authorize my representative or family to make this decision when I die.
________
B. I DO NOT WANT to make an organ or tissue donation, and I do not want this donation
authorized on my behalf by my representative or my family.
________
C. I DO WANT to make an organ or tissue donation when I die. The following are my directions:
________
Organs/Tissues I choose to donate (Select a or b below):
________
a. Any needed parts or organs.
________
b. These specific parts or organs: _____________________________
_________________________________________________________
_________________________________________________________
________
What Purposes I donate Organs/Tissues for (Select a, b, or c below):
________
a. Any legally authorized purpose (transplantation, therapy, medical and
dental evaluation and research, and/or advancement of medical and
dental science).
________
b. Transplant or therapeutic purposes only.
________
c. Other: _________________________________________________
________
What organization or person I want my parts or organs to go to:
________
a. I have already signed a written agreement or donor card regarding
organ and tissue donation with the following individual or institution:
(Name) ___________________________________________________
__________________________________________________________
________
b. I would like my tissues or organs to go to the following individual or
institution: (Name) __________________________________________
__________________________________________________________
________
c. I authorize my representative to make this decision.
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