Colorado Declaration As To Medical Or Surgical Treatment - Medical Durable Power Of Attorney For Healthcare Page 3

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WITNESSES
I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged
this Medical Durable Power of Attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud
or undue influence. I am not the person appointed as the agent by this document, nor am I the patient’s healthcare provider, or an
employee of the patient’s healthcare provider.
First Witness’ Signature _________________________________________________
Home Address ________________________________________________________
Print Name ___________________________________________________________
Date ________________________________________________________________
Second Witness’ Signature _______________________________________________
Home Address ________________________________________________________
Print Name ___________________________________________________________
Date ________________________________________________________________
AN ORGANIZATION OF
AMERICANS FOR LEGAL REFORM
Email:
Phone: 1-888-FOR-HALT
(202) 887-8255
Fax: (202) 887-9699
1612 K Street, NW Suite 510
Washington, DC 20006

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