Health Care Directive Form
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1
2Health Care Directive
Please type or print legibly
This is the Health Care Directive of:
Name
Address
City
City
Province
Postal Code
Telephone (
Telephone (
)
)
Part 1 – Designation of a Health Care Proxy
Part 2 – Treatment Instructions
You may name one or more persons who will have the power
In this part, you may set out your instructions concerning
to make decisions about your medical treatment when you lack
medical treatment that you do or do not wish to receive and the
the ability to make those decisions yourself. If you do not wish
circumstances in which you do or do not wish to receive that
to name a proxy, you may skip this part.
treatment. REMEMBER – your instructions can only be carried
out if they are set out clearly and precisely. If you do not wish to
I hereby designate the following person(s) as my Health
provide any treatment instructions, you may skip this part.
Care Proxy:
Proxy 1
Name
Address
Address
City
Province
Postal Code
Telephone (
)
Part 3 – Signature and Date
Proxy 2
You must sign and date this Health Care Directive.
No witness is required.
Name
Address
Signature
Date
City
If you are unable to sign yourself, a substitute may sign
Province
Postal Code
on your behalf. The substitute must sign in your presence
Telephone (
)
and in the presence of a witness. The proxy or the proxy’s
spouse cannot be the substitute or witness.
(Check one choice only.) For an explanation of “consecutively”
and “jointly” please see the reverse side of this form).
Name of substitute:
Name of substitute:
If I have named more than one proxy,
Address
I wish them to act:
consecutively
jointly
OR
Signature
My Health Care Proxy may make medical decisions on
Date
my behalf when I lack the capacity to do so for myself
(check one choice only):
With no restrictions
Name of witness:
With restrictions as follows:
Address
Signature
Date
MG-3598 (Rev. 05/04)
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