Medical Power Of Attorney Form Page 2
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6V. PRINCIPAL - I, ______________________, residing at
Name of Principal
_________________________________________________________________
Street Address of Principal
City of ______________________, State of ______________________, appoint
City of Principal
State of Principal
the following as my Medical Attorney-in-Fact, whom I trust with any and all my
medical decision making in the event that I should become incapacitated:
VI. MEDICAL ATTORNEY-IN-FACT - ______________________, residing at
Name of Medical Attorney-in-Fact
_________________________________________________________________
Street Address of Medical Attorney-in-Fact
City of ______________________, State of ______________________ grant
City of Medical Attorney-in-Fact
State of Medical Attorney-in-Fact
the Medical Attorney-in-Fact the legal authority to act on my behalf for any
power legal under law in regard to my medical decisions under the State of
_________________________.
State
By signing this Medical Power of Attorney Form the Medical Attorney-in-Fact
accepts this appointment and to act in the Principal’s best interest. This
Medical Power of Attorney Form may be revoked by the Principal at anytime
and is automatically by law void upon the Principal’s death.
The Medical Attorney-in-Fact includes making any medical decisions on my
behalf and as set forth below.
VII. TERMS & CONDITIONS - If the Principal has authorized a Living Will or
Directive to Physicians, and it is still in effect, I direct that my Medical
Attorney-in-Fact abide by the directions that I have set forth in that document.
If at any time the Principal should have an incurable injury, disease, or illness
which has been certified as a terminal condition by the Principal’s attending
physician and one additional physician, both of whom have personally
examined the Principal, and such physicians have determined that there can be
no recovery from such condition and the Principal’s death is imminent, and
where the application of life prolonging procedures would serve only to
artificially prolong the dying process, then:
The Principal appoints the Medical Attorney-in-Fact to assure that such
procedures be withheld or withdrawn, and that the Principal be permitted to
die naturally with only the administration of medication, the administration of
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