Advanced Directive Form Page 4
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4Mental Competence.
For purposes of this Advance Directive, a person shall be considered to be
incompetent if and while the person is a minor, or is judged by the court to be incompetent, or is unable to give
prompt and intelligent consideration to health care matters as certified by a licensed physician.
This Advance Directive shall become effective whenever I become mentally incompetent, and it shall terminate
whenever I regain mental competence.
Alternate Agents.
If any agent named by me shall become incompetent, unwilling or otherwise unavailable
to act as my agent, I name the following as alternate agents (with only one empowered at a time):
_________________________
_________________________________________________________
(Name: First Choice)
(Address)
________________________
_________________________
(Daytime Phone Number)
(Evening Phone Number)
_________________________
_________________________________________________________
(Name: Second Choice)
(Address)
________________________
_________________________
(Daytime Phone Number)
(Evening Phone Number)
Signatures.
I am fully informed as to all the contents of this form and understand this grant of powers to my agent.
Principal:
___________________________________________________________________________
(Signature)
(Date)
___________________________________________________________________________
(Address)
(Telephone number)
The principal has had an opportunity to read this Advance Directive and has signed the form or acknowledged
his or her signature or mark on the form in my presence.
Witness #1:
___________________________________________________________________________
(Printed Name)
(Signature)
(Date)
___________________________________________________________________________
(Address)
(Telephone Number)
Witness #2:
___________________________________________________________________________
(Printed Name)
(Signature)
(Date)
___________________________________________________________________________
(Address)
(Telephone Number)
Specimen signatures of agent
I certify that the signatures of my agent
(and alternate agents)
(and alternate agents) are correct
Agent:
_________________________________
Principal:
______________________________
Alternate Agent #1:
_______________________
Principal:
______________________________
Alternate Agent #2:
_______________________
Principal:
______________________________
Form provided by The Center for Bioethics and Human Dignity ( )
2065 Half Day Road, Bannockburn, IL 60015, Phone: 847-317-8180, Email:
Page 2
Printed 01-06-04
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