Medical Health Care Proxy Form
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1Medical Health Care Proxy
The primary physician of ________________________________ has advised the following “interested parties” who
(patient name)
may include a spouse, parent, adult children, brother or sister, grandchildren or close friend(s),
that _______________________________________ lacks decisional capacity in matters of personal health care
(patient name)
and so is not able to give informed consent to or refusal of medical treatment, use of cardio-pulmonary resuscitation
or the administration of artificial nourishment or hydration to prolong the act of dying.
By consensus, the undersigned agree that _______________________________________________ should act as
(
Designated Proxy Decision Maker)
Proxy Decision Maker for _______________________________________ with respect to any and all decisions
(patient name)
without limitations with respect to termination or withholding of life support in accordance with the authority set forth
under Colorado law, Section 15-18.6 of the Colorado Revised Statues.
____________________________________________________________________________________________
Signature
Date
Relationship
___________________________________________________________________________________________________________________
_
Signature
Date
Relationship
____________________________________________________________________________________________
Signature
Date
Relationship
____________________________________________________________________________________________
Signature
Date
Relationship
The foregoing instrument was signed and declared by ______________________________as his/her voluntary act.
(Designated Proxy Decision Maker)
on this ___________ day of ___________________, 20_____.
State of Colorado
County of ____________________________
Witness my hand and seal
Notary Public ______________________________________________
My Commission expires:
Address __________________________________________________
Each medical institution has an individually designed Medical Health Care Proxy Form.
An individual may have to sign a separate form for each health care institution, such as a hospital, nursing
home, or hospice if the patient receives care in more than one institution.
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