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

2007 Advanced Directive Template Page 5

Advanced Directive

PART 4. Signatures

You and two witnesses must sign this document before it will be legal.

A. Your signature

By my signature below, I show that I understand the purpose and the effect of this document.

Signature:

Date:

Address:

B. Your witnesses' signatures

I believe the person who has signed this advance directive to be of sound mind, that he/she signed or

acknowledged this advance directive in my presence and that he/she appears not to be acting under pressure,

duress, fraud or undue influence. I am not related to the person making this advance directive by blood, marriage

or adoption nor, to the best of my knowledge, am I named in his/her will. I am not the person appointed in this

advance directive. I am not a health care provider or an employee of a health care provider who is now, or has

been in the past, responsible for the care of the person making this advance directive.

Witness #1

Signature:

Date:

Address:

Witness #2

Signature:

Date:

Address:

Created: 09/20/2007

Pinnacle Family Medicine, P.L.C.

page 5 of 5

2007 Advanced Directive Template Page 5