Advance Medical Directive Worksheet (Page 2 of 7) in pdf

Advance Medical Directive Worksheet Page 2

declaration, whenever the declarant is incapable of

death decisions to be made by your agent, you

making informed health care decisions.

should also execute a Living Will to ensure that

the doctor is certain of your decision and will

carry out your agent's decision on this matter.

Please prepare the requested legal document(s) for me using the

information provided below.

Client's signature

Date: Day __________ Month _________ 19_____

PLEASE Ö CHECK YOUR STATUS: o ACTIVE DUTY o DEPENDENT o RETIREE

NAVY _____ USNR _____ USMC _____ USMCR _____

USCG _____ USCGR _____ ARMY _____ USAR _____

USAF _____ USAFR _____ OTHER (specify)

SPONSOR'S UNIT: _________________________

SPONSOR'S RANK/RATE : __________ YOUR PHONE #:

___________________________

ADVANCE MEDICAL DIRECTIVE WORKSHEET

On this Worksheet, you will be providing information necessary for the Legal Assistance

Office to draft two documents that express your intent regarding health care decisions

and/or your desire to die a natural death in the event you are unable to communicate these

decisions.

Advance Medical Directive Worksheet Page 2