Power Of Attorney For Health Care Decisions Form Page 2
Download a blank fillable Power Of Attorney For Health Care Decisions Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Power Of Attorney For Health Care Decisions Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2I hereby declare that, with respect to the powers conferred by this executed instrument,
any and all such powers which may have been conferred in a previously executed
instrument or instruments are hereby revoked.
I further instruct that, upon being informed that my attending physician has determined
that I am unable to understand and appreciate the nature and consequences of health care
decisions and unable to reach and communicate an informed decision regarding
treatment, my attorney-in-fact to execute an affidavit stating said determination has
occurred.
In Witness Whereof, I have hereunto signed my name and affixed my seal this _____
day of ________________________, 200____.
Signed, sealed and delivered in presence of:
_____________________________
Signature of Principal
x____________________________
x ____________________________
(Witness)
(Witness)
____________________________
_____________________________
(Number and Street)
(Number and Street)
x____________________________
____________________________
(City, State and Zip Code)
(City, State and Zip Code)
STATE OF CONNECTICUT
)
:
ss. _______________________
(Town)
COUNTY OF ________________________
)
The foregoing POWER OF ATTORNEY was acknowledged before me this day _______
of _____________________, 200____, by ____________________________________.
(Principal)
__________________________________
Commissioner of the Superior Court
Notary Public
My Commission expires:____________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal