Medical Power Of Attorney (Page 2 of 2) in pdf

Medical Power Of Attorney Page 2

A Health Care Professional or Health Care Institution that relies in good faith on a consent or waiver

given under this Medical Power of Attorney shall incur no liability for any act or omission

undertaken at the direction of my Health Care Representative.

For purposes of identification, the signature of my Health Care Representative is as follows:

____________________________________

Signature of HCR

This document has been explained to me and my Agent by________________________________.

I understand the content of this document and I voluntarily sign this statement.

IN WITNESS WHEREOF, I have hereunto set my hand and seal,______________________this day

of _________________________________.

WITNESS:

_____________________________

____________________________(L.S.)

AS TO

Client

STATE OF NEW JERSEY )

)SS:

COUNTY OF ESSEX

)

BE IT REMEMBERED, that on this______day of ________, 2006, before me, an Attorney at Law

of the State of New Jersey, personally appeared___________________, who I am satisfied, is the

person mentioned in and who executed the within instrument and to whom I first made known the

contents thereof, and thereupon he/she acknowledged that he/she signed by his/her mark, sealed and

delivered the same as his/her voluntary act and deed for the uses and purposes therein expressed.

____________________________________

Attorney at Law, State of New Jersey

This document has been explained to me by_______________________. I understand the content

of this document, and I voluntarily sign this statement. No one has forced me to do this.

____________________________________

Signature of Client

Medical Power Of Attorney Page 2