Fillable My Advance Care Plan (Page 2 of 4) in pdf

Surname: ___________________________

First Name/s: ________________________

NHI Number: _________ DOB: __ / __ / __

Address: ___________________________

__________________________________

Phone: __________ Mobile: ____________

MY ADVANCE CARE PLAN

Please use this plan to inform my care only if I am unable to inform you directly

My Enduring Power of Attorney

(for personal care and welfare)

First name(s):

Last name:

Relationship

...............................................................

...................................................................

.............................................

Address:

........................................................................................................................................................................................................................................................

Home Phone:

Daytime Phone:

Mobile Phone:

...............................................

Please try to include the following people in decisions about my care:

First name:

Last name:

Relationship:

Phone:

............................................

.............................................

.................................

...................................

First name:

Last name:

Relationship:

Phone:

............................................

.............................................

.................................

...................................

First name:

Last name:

Relationship:

Phone:

............................................

.............................................

.................................

...................................

First name:

Last name:

Relationship:

Phone:

............................................

.............................................

.................................

...................................

I have made a Will (tick):

Yes  No



It is held by:

...................................................................................................

If I can no longer tell you myself I want those who care for me to know:

The following is important to me:

(this can include your hopes and fears, practical matters (eg you like the TV on, you like to be

outside), family concerns, spiritual care you would like, anything else you can think of)

...........................................................................................................................................................................................

This is what makes life meaningful to me (this may include values, people, pets, ways you would like

those caring for you to look after your spiritual and emotional needs, and anything else you want);

...........................................................................................................................................................................................

I would like my family and friends to know and remember these things:

...........................................................................................................................................................................................

Page 2 of 4

My Advance Care Plan Page 2

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