Durable Health Care Power Of Attorney Instructions And Form (Page 5 of 12) in pdf

Durable Health Care Power Of Attorney Instructions And Form Page 5

DURABLE HEALTH CARE POWER OF ATTORNEY (Last Page)

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: _________________________________________________________________________________

_______________________________________________________________________________________________________________

Developed by the Office of Arizona Attorney General

Updated January 18, 2011

TOM HORNE

(All documents completed before January 18, 2011 are still valid)

DURABLE HEALTH CARE POWER OF ATTORNEY

Durable Health Care Power Of Attorney Instructions And Form Page 5