Health Care Proxy Form

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HEALTH CARE PROXY FORM
l) I, ____________________________________________________________________ , hereby appoint
____________________________________________________________________________________
___________
(Agent’s name, home address and phone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I state oth-
erwise. This proxy shall take effect when and if I become unable to make my own health care decisions.
2) Optional: Alternate Agent. If the person I appoint is unable, unwilling or unavailable to act as my health
care agent, I hereby appoint:
____________________________________________________________________________________
__________________
(name, home address and telephone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.
3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall
remain in effect indefinitely. Optional: If you want this proxy to expire, state the date or conditions here.
This proxy shall expire (specify date or conditions): __________________________________________
4) Optional: I direct my health care agent to make health care decisions according to my wishes and limita-
tions, as he or she knows or as stated below. (If you want to limit your agent’s authority to make health care
decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my
health care agent to make health care decisions in accordance with the following limitations and/or instruc-
tions (attach additional pages as necessary): ________________________________________________
____________________________________________________________________________________
In order for your agent to make health care decisions for you about artificial nutrition and hydration (nour-
ishment and water provided by feeding tube and intravenous line), your agent must reasonably know your
wishes. You can either tell your agent what your wishes are or include them in this section. See instructions
for sample language that you could use if you choose to include your wishes on this form.
5) Optional: Organ and/or Tissue Donation
I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)
Any needed organs and/or tissues
The following organs and/or tissues ___________________________________________________
Limitations ______________________________________________________________________
Failure to state wishes or instructions shall not be construed to imply a wish not to donate.
6) Your Identification: (please print) Your Name ___________________________________________
Your Signature ______________________________________________ Date ____________________
Your Address _________________________________________________________________________
7) Statement by 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 (print) _______________________ Address _______________________________________
Signature __________________________________________________Date ______________________
Witness 2 (print) _______________________ Address _______________________________________
Signature __________________________________________________Date ______________________
I have a health care proxy. In case of emergency, please notify my health care agent:
My Name: _____________________________________________________
Address: _______________________________________________________
_________________________________Phone: _______________________
My Agent: _____________________________________________________
Agent’s Address: _________________________________________________
Agent’s Phone: _______________ Agent’s E-mail: ______________________

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