Health Care Directive (Living Will) (Page 4 of 4) in pdf

Health Care Directive (Living Will) Page 4

Page 3 of 3

(Optional Clauses)

Proxy:

The following person is named to act as my proxy for health care. As my

proxy, this person is authorized to consent to my health care when I am

unable to communicate AND to consent to withdrawal of treatment on

my behalf when the circumstances as described in part 1, page 2 of this

directive come into effect.

(1) _________________________________ Phone ________________

Address___________________________________________AND/OR

(1) _________________________________ Phone ________________

Address___________________________________________AND/OR

(1) _________________________________ Phone ________________

Address___________________________________________AND/OR

I consent to the use after my death of any needed organs or parts

of my body for transplantation.

If I am pregnant, and there is any prospect that the child can sur-

vive, this directive shall have no force during the course of my

pregnancy.

SIGNED AND DECLARED

by the said _________________________________________________

this ____________ day of ________________________, A.D 20______

________________________________

_____________________________

Witness

Address

_____________________________

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Health Care Directive (Living Will) Page 4