Advance Medical Directive Worksheet (Page 5 of 7) in pdf

Advance Medical Directive Worksheet Page 5

Note: The guardian may, and often is, the same person designated as the

first agent. A guardian of your person may be appointed for you if a court

decides that one should be appointed. The guardian of your person is

responsible for your physical care, which under some circumstances includes

making health care decisions.

9. I specifically desire that the following person act as my guardian:

Full Name: ___________________________________

Relationship: _______________________________(i.e. spouse, sister,

brother)

Address: _______________________________________ (street)

________________________

__________________

________________________

__________________(city,

state, zip code)

Telephone: _______________________

PHYSICIAN AUTHORIZED TO DETERMINE INCOMPETENCY OR

INCAPACITATION

Note: It is not required that you specifically name a doctor. Instead, you may

authorize "the attending physician" responsible for your care to make the

decision.

10. I desire that the following doctor make the decision regarding my

incompetency or incapacity:

Advance Medical Directive Worksheet Page 5