Medical Power Of Attorney Form printable pdf download

Medical Power Of Attorney Form

Medical Power of Attorney

Date

____/____/______

I, do hereby

[Legal Name]

A resident of

[City][State]

Located at

[Address]

[City], [State] [Zip Code]

Do Hereby Appoint

[Legal Name]

A resident of

[City][State]

Located at

[Address]

[City], [State] [Zip Code]

As my attorney-in-fact to make any and all health care decisions for me, except to the extent I

state otherwise in this document. This Medical Power of Attorney takes effect if I become

unable to make my own health care decisions and my physician certifies this fact in writing. The

following are limitations on the decision making authority of my agent:

______________________________________________________________________________

If the above designated person as my agent is unable or unwilling to make healthcare decisions

for me, I hereby designate the following persons to serve as my agent to make health care

decisions for me as is authorized by this document, who may serve in the following order:

First Alternate:

Do Hereby Appoint

[Legal Name]

A resident of

[City][State]

Located at

[Address]

[City], [State] [Zip Code]

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Medical Power Of Attorney Form