Durable Power Of Attorney For Health Care Page 4
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5[____________]
I CHOOSE to make a partial anatomical gift of some of my organs or
tissue as specified below, and artificial support may be maintained long
enough for organs to be removed. The following organs and tissue may be
donated:
_______________________________________________________
[____________]
I REFUSE to make an anatomical gift of any of my organs or tissue.
[____________]
I CHOOSE to let my agent decide.
(11)
OTHER WISHES: (If you wish to write your own instructions for either health
care or end-of-life decisions, or if you wish to add to the instructions you have given above, you
may do so here.) I direct that:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Add additional sheets if needed. Sheets should be signed and dated.)
PART 3
PRIMARY PHYSICIAN
(12)
I designate the following physician and/or facility as my primary physician:
______________________________________________________________________________
(name of physician)
______________________________________________________________________________
(address)
(city)
(state)
(zip code)
______________________________________________________________________________
(phone)
If the physician I have designated above is not willing, able or reasonably available to act
as my primary physician, I designate the following physician as my primary physician:
______________________________________________________________________________
(name of physician)
______________________________________________________________________________
(address)
(city)
(state)
(zip code)
______________________________________________________________________________
(phone)
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