My Advance Care Plan Page 4
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4Surname: ___________________________
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
Specific Treatment and Care Preferences
(please fill out with the help of your Doctor or Nurse)
These expressed preferences should be used to guide clinical decisions in the circumstances that I have
set out below:
I would / would not want:
In these circumstances:
For Signature
1.
I understand this is a record of my preferences to guide my healthcare team in providing appropriate care for me.
2.
I understand that it will only be used when I am unable to make decisions for myself.
3.
I understand that medically futile and/or inappropriate treatments will not be administered even if this is my expressed
preference.
4.
I acknowledge that this record may be held in an electronic form and will be made available to other health care
providers for purposes of treating me.
Signed:
Date:
.........................................................................................................................................
.........................................................................................
Witness (Health Professional):
Signed:
Date:
.........................................................................................................................................
.........................................................................................
First Name(s): ............................................................. Last Name: ...................................................... Designation: ....................................
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Parent category: Medical