Durable Power Of Attorney For Health Care Decisions Page 9
Download a blank fillable Durable Power Of Attorney For Health Care Decisions 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 Durable Power Of Attorney For Health Care Decisions 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
6
7
8
9
10
11
12[ ] I consent to the administration of the following medications:
________________________________________________________________________
[ ] I do not consent to the administration of the following medications:
________________________________________________________________________
Conditions or limitations:
(10) ELECTROCONVULSIVE TREATMENT.
If I do not have the capacity to
give or withhold informed consent for mental health treatment, my wishes regarding
electroconvulsive treatment are as follows:
[ ] I consent to the administration of electroconvulsive treatment.
[ ] I do not consent to the administration of electroconvulsive treatment.
Conditions or limitations:
___________________________________________________________________
(11) ADMISSION TO AND RETENTION IN FACILITY.
If I do not have the
capacity to give or withhold informed consent for mental health treatment, my
wishes regarding admission to and retention in a mental health facility for
mental health treatment are as follows:
[ ] I consent to being admitted to a mental health facility for mental health
treatment for up to ________ days. (The number of days not to exceed 17.)
[ ] I do not consent to being admitted to a mental health facility for mental
health treatment.
Conditions or limitations:
___________________________________________________________________
OTHER WISHES OR INSTRUCTIONS
Conditions or limitations:
___________________________________________________________________
9
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal