Health Care Proxy Form printable pdf download

Instructions for filling out this proxy form:

ITEM I: Write your name and the name, home address and tele-

ITEM 4: This form will remain valid indefinitely unless you set

phone number of the person you are selecting as your agent.

expiration date or condition for its expiration. This section is

optional and should be filled in only if you want the health care

ITEM 2: If you have special instructions for your agent, you

proxy to expire at some point in time.

should write them here. Also, if you wish to limit your agent's

authority in any way, you should say so here. If you do not state

ITEM 5: You must date and sign the proxy. If you are unable to

any limitations, your agent will be allowed to make all health care

sign yourself you may direct someone else to sign in your presence.

decisions that you could have made, including the decision to

Be sure to include your address.

consent to or refuse life-sustaining treatment.

ITEM 6: Two witnesses at least 18 years of age must sign your

ITEM 3: You may write the name, home address and telephone

proxy. The person who is appointed agent or alternate agent cannot

number of an alternate agent.

sign as a witness.

HEALTH CARE PROXY

Please print in ink

1.I,

hereby appoint: Name

Address

Telephone

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.)

Note: 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

3. Name of substitute of alternate agent if the person I appoint above is unable, unwilling. or unavailable to act as

my health care agent.

Name

Address

Telephone

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

6. 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

Health Care Proxy Form

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