Healthix Consent Form
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1
2Health Care Proxy
(1)
I, ________________________________________, hereby appoint __________________________________,
residing at _______________________________________________________________, whose telephone
number is ____________________, 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: 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.
This health care proxy contains no limitations. I have discussed my wishes with my Agent and Substitute Agent
and each knows my wishes concerning artificial nutrition and hydration.
(3)
Optional: I hereby make an anatomical gift, to be effective upon my death of: (check all that apply)
Any needed organs and/or tissues
The following organs and/or tissues: _________________________________________________________
Limitations: ____________________________________________________________________________
If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken
to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to
consent to a donation on your behalf.
(4)
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: _________________, residing at ________________________________________________,
whose telephone number is ____________________.
(5)
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): ___________________________________________
(6)
Signature: _____________________________________________
Address: __________________________________________________________________________________
Date: _________________
Statement by Witnesses (must be 18 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 _______________________________________________________________________________________
Address
_______________________________________________________________________________________
Witness 2 _______________________________________________________________________________________
Address
_______________________________________________________________________________________
DAVIDOW, DAVIDOW, SIEGEL & STERN, LLP
Garden City Office
Islandia Office
Mattituck Office
666 Old Country Road
1050 Old Nichols Road
P.O. Box 344
Suite 100
Suite 810
13235 Main Road
Islandia, NY 11749
Garden City, NY 11530
Mattituck, NY 11952
*Executing the above heath care proxy form does not in any way take the place of legal advice from a qualified elder law attorney. The above health care proxy form does not in any way take the place of a well
thought out estate plan. It is only one element of incapacity planning and should be used in conjunction with a more complete estate plan.
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Parent category: Medical