Medical Power Of Attorney Form Page 3
Download a blank fillable Medical Power Of Attorney Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Power Of Attorney Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6nutrition and/or hydration, or the performance of any medical procedure
deemed necessary to provide me with comfort, care, or to alleviate pain.
If at anytime the Principal should have been diagnosed as being in a persistent
incurable state unconsciousness which has been certified as incurable by the
Principal’s attending physician and one additional physician, both of whom
have personally examined the Principal, and said physicians have determined
that there can be no recovery from such condition, and where the application
of life prolonging procedures would serve only to artificially prolong the dying
process, then:
The Principal direct that my Medical Attorney-in-Fact 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procedures be withheld or withdrawn, and that the Principal be permitted to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
nutrition and/or hydration, or the performance of any medical procedure
deemed necessary to provide me with comfort, care, or to alleviate pain.
The
f ollowing
s tatements
o nly
a pply
i f
t he
P rincipal
s igns
b elow
t his
l ine
____________________________________________________________________
Signature of Principal
However, if at any time the Principal should have been diagnosed as being in a
permanent state of unconsciousness which has been certified as incurable by
the Principal’s attending physician and one additional physician, both of them
whom personally examined the Principal, and such physicians have determined
that there can be no recovery from such condition, the Principal also directs
that the Medical Attorney-in-Fact have sole authority to order the withholding
of any aid, including the administration of nutrition, hydration, and any other
medical procedure deemed necessary to provide me with comfort, care, or to
alleviate pain.
If the Principal is able to communicate in any manner, including even blinking
my eyes, I direct that my health care representative try and discuss with me
the specifics of any proposed medical decision.
If the Principal has any further terms and conditions, state them here:
Other Terms and Conditions
I, the Principal, fully understand the terms under this Medical Power of
Attorney Form, as well as fully acknowledge the acceptance of the Medical
Attorney-in-Fact that will conduct all medical decision making on my behalf. I
have full faith and confidence in their judgment to either serve out my wishes
or in my best interest as stated above. Furthermore, shall I not able to make
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal