Fillable Advance Directive (Page 2 of 7) in pdf

Advance Directive Page 2

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Complete Advance Directive with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Print your NAME, BIRTHDATE, and ADDRESS here:

__________________________________________________________

(Name)

__________________________________________________________

(Birthdate)

__________________________________________________________

(Address)

Unless revoked or suspended, this advance directive will continue for:

INITIAL ONE:

_______ My entire life

_______ Other period (_______ Years)

PART B: APPOINTMENT OF HEALTH CARE REPRESENTATIVE

I appoint ___________________________________________ as my health care representative.

My representative’s address is _____________________________________________________

and telephone number is __________________________.

I appoint ________________________________________________ as my alternate health care

representative. My alternate’s address is _____________________________________________

and telephone number is __________________________.

I authorize my representative (or alternate) to direct my health care when I can’t do so.

NOTE: You may not appoint your doctor, an employee of your doctor, or an owner, operator or

employee of your health care facility, unless that person is related to you by blood, marriage or

adoption, or that person was appointed before your admission into the health care facility.

Advance Directive Page 2

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