2007 Advanced Directive Template (Page 2 of 5) in pdf

2007 Advanced Directive Template Page 2

Advanced Directive

Complete this portion of advance directive form

I, ________________________________________________, write this document as a directive regarding my

medical care.

In the following sections, put the initials of your name in the blank spaces by the choices you want.

PART 1. My Durable Power of Attorney for Health Care

I appoint this person to make decisions about my medical care if there ever comes a time

______

when I cannot make those decisions myself. I want the person I have appointed, my

doctors, my family and others to be guided by the decisions I have made in the parts of

the form that follow

Name

Home telephone:

Work telephone:

Address:

If the person above cannot or will not make decisions for me, I appoint this person:

Name:

Home telephone:

Work telephone:

Address:

I have not appointed anyone to make health care decisions for me in this or any

______

2007 Advanced Directive Template Page 2