Georgia Advance Directive For Health Care (Page 5 of 6) in pdf

8. Additional Statements

This section is optional. PART TWO will be effective even if this section is left blank. This section allows you to state additional

treatment preferences, to provide additional guidance to your health care agent (if you have selected a health care agent in

PART ONE), or to provide information about your personal and religious values about your medical treatment. For example,

you may want to state your treatment preferences regarding medications to fight infection, surgery, amputation, blood

transfusion, or kidney dialysis. Understanding that you cannot foresee everything that could happen to you after you can no

longer communicate your treatment preferences, you may want to provide guidance to your health care agent (if you have

selected a health care agent in PART ONE) about following your treatment preferences. You may want to state your specific

preferences regarding pain relief.

9. In Case of Pregnancy

PART TWO will be effective even if this section is left blank.

I understand that under Georgia law, PART TWO generally will have no force and effect if I am pregnant unless the

fetus is not viable and I indicate by initialing below that I want PART TWO to be carried out.

_________ (Initials) I want PART TWO to be carried out if my fetus is not viable.

PART THREE—Guardianship

10. Guardianship

PART THREE is optional. This advance directive for health care will be effective even if PART THREE is left blank. If you wish

to nominate a person to be your guardian in the event a court decides that a guardian should be appointed, complete PART

THREE. A court will appoint a guardian for you if the court finds that you are not able to make significant responsible decisions

for yourself regarding your personal support, safety, or welfare. A court will appoint the person nominated by you if the court

finds that the appointment will serve your best interest and welfare. If you have selected a health care agent in PART ONE,

you may (but are not required to) nominate the same person to be your guardian. If your health care agent and guardian are

not the same person, your health care agent will have priority over your guardian in making your health care decisions, unless

a court determines otherwise.

State your preference by initialing (A) or (B). Choose (A) only if you have also completed PART ONE.

(A) _________ (Initials) I nominate the person serving as my health care agent under PART ONE to serve as my

guardian.

(B) _________ (Initials) I nominate the following person to serve as my guardian:

Name:

Address:

Telephone Numbers:

(Home, Work, and Mobile)

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Georgia Advance Directive For Health Care Page 5