Physician'S Certificate Of Competence
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1PHYSICIAN’S CERTIFICATE OF COMPETENCE
I, ____________________________ , M.D., hereby certify as follows:
1. That I am a physician duly licensed to practice medicine in the State of Maryland, having
specialized in the field of _____________________________ for ________ years.
2. That on the _______ day of __________________________ , 20 ____ , I examined
__________________________.
3. I am of the opinion that _______________________ is able to understand the nature, extent, or probable
consequences of any proposed medical treatment, is able to make a rational evaluation of the burdens,
risks, and benefits of any proposed medical treatment, and is able to communicate a decision regarding any
proposed medical treatment.
4. I am also of the opinion that _____________________________ is capable of comprehending the meaning
of legal documents such as a Power of Attorney, Last Will and Testament, Living Will and Deed, and has
the capacity to consent to the execution of these legal documents on his/her behalf.
I do hereby further certify under the penalties of perjury, that all of the statements set forth in the aforegoing
Certificate are true and correct to the best of my knowledge, information and belief.
Date: ____________________
__________________________________
Physician's Signature
__________________________________
(Physician's printed name)
__________________________________
Address
_________________________________
__________________________________
Phone number
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