Application For Admission To The New York Armenian Home (Page 7 of 10) in pdf

Application For Admission To The New York Armenian Home Page 7

Health Care Proxy

1) 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. This proxy shall take effect when and if I become unable to make my own health care

decisions.

2) Optional instructions: I direct my agent to make health care decisions in accord with my wishes and

limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary.)

(Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes), your agent

will not be allowed to make decisions about artificial nutrition and hydration. See instructions on reverse

for samples of language you could use.)

3) Name of substitute or fill-in agent if the person I appoint above is unable, unwilling or unavailable to act as

my health care agent.

(Name, home address and telephone number)

4) Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions stated below.

This proxy shall expire (specific date or conditions, if desired):

5) Signature

Address

Date

Statement by Witnesses (must be 18 or older)

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.

Address

Witness 2.

Address

Application For Admission To The New York Armenian Home Page 7