State Of Arizona Living Will (End Of Life Care) Page 9
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9Notary Public (NOTE: a Notary Public is only required if no witness signed above):
STATE OF ARIZONA ss
COUNTY OF ______________________)
The undersigned, being a Notary Public certified in Arizona, declares that the person
making this Durable Health Care Power of Attorney has dated and signed or marked it in
my presence and appears to me to be of sound mind and free from duress. I further
declare I am not related to the person signing above by blood, marriage or adoption, or a
person designated to make medical decisions on his/her behalf. I am not directly involved
in providing health care to the person signing. I am not entitled to any part of his/her
estate under a will now existing or by operation of law. In the event the person
acknowledging this Durable Health Care Power of Attorney is physically unable to sign
or mark this document, I verify that he/she directly indicated to me that this Durable
Health Care Power of Attorney expresses his/her wishes and that he/she intends to adopt
the Durable Health Care Power of Attorney at this time.
WITNESS MY HAND AND SEAL this
day of ______________, 20
Notary Public
My Commission Expires:
__________________
OPTIONAL:
STATEMENT THAT YOU HAVE DISCUSSED
YOUR HEALTH CARE CHOICES FOR THE FUTURE
WITH YOUR PHYSICIAN
NOTE: Before deciding what health care you want for yourself, you may wish to ask
your physician questions regarding treatment alternatives. This statement from your
physician is not required by Arizona law. If you do speak with your physician, it is a
good idea to have him or her complete this section. Ask your doctor to keep a copy of
this form with your medical records.
On this date I reviewed this document with the Principal and discussed any questions
regarding the probable medical consequences of the treatment choices provided above. I
agree to comply with the provisions of this directive, and I will comply with the health
care decisions made by the representative unless a decision violates my conscience. In
such case I will promptly disclose my unwillingness to comply and will transfer or try to
transfer patient care to another provider who is willing to act in accordance with the
representative's direction.
Doctor Name (printed):
Signature:
Date:
Address:
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