Wishes For Health Care: Short Form - Minnesota Health Care Directive
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Wishes for Health Care: Short Form
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Minnesota Health Care Directive
S
ee other side for completion directions
Full Name: _______________________________________________ Date of birth: _________________________
1. I appoint the following person to serve as my primary (main) health care agent. This person will make health
care decisions for me if I cannot communicate or make these decisions myself:
Name ____________________________________________ Relationship _____________________________
Cell phone _______________________________ Other phone _____________________________________
(Optional): I appoint this person as my alternate health care agent in the event my first health care agent is
not available:
Name ___________________________________________ Relationship ______________________________
Cell phone _______________________________ Other phone _____________________________________
2. (Optional): I give the following instructions about my health care (my values and beliefs, what I do and do
not want, views about specific medical treatments or situations): If you need more space, continue on other
side.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Signature _________________________________________________ Date_______________________________
Notary Public in the State of Minnesota
County of ________________________________________________________
Notary seal
In my presence on ____________ (date), ____________________________ (name)
acknowledged his or her signature on this document, or acknowledged that he or
she authorized the person signing this document to sign on his or her behalf.
Signature of Notary ____________________________________________________
My commission expires _____________________________________________(date)
OR Statement of Witnesses
Witness 1 __________________________________ Witness 2 __________________________________
Print Name: ________________________________ Print Name: ________________________________
(Witnesses must be 18 years of age or older and cannot be your primary or alternate health care agent.
One witness cannot be your health care provider or an employee of your health care provider.)
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A long form is available if you wish to more fully describe your health care wishes.
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This document will not apply to any intrusive mental health treatments (electroconvulsive therapy or neuroleptic medications).
Honoring Choices Minnesota is an initiative of the Twin Cities Medical Society.
612-362-3704
Revised July 2014
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