Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will Page 5
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7VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
C - ADDITIONAL PREFERENCES
This section is optional. In this space, you can write other important preferences for your health care that
aren’t described somewhere else in this document. For example, these might be social, cultural, or
faith-based preferences for care, or preferences about treatments such as feeding tubes, blood transfusions,
or pain medications. If you need more space, you may attach extra pages and use this space to refer to
attached pages. Be sure to initial and date every page that you attach.
D - HOW STRICTLY YOU WANT YOUR PREFERENCES FOLLOWED
Place your initials in the box next to the statement that reflects how strictly you want others to follow your
preferences. Choose only one.
Initials
I want my preferences, as expressed in this Living Will, to serve as a general guide. I understand
that in some situations, the person making decisions for me may decide something different from the
preferences I express above, if they think it's in my best interests.
Initials
I want my preferences, as expressed in this Living Will, to be followed strictly, even if the person
making decisions for me thinks that this isn't in my best interests.
VA FORM
10-0137
Page 5 of 7
JUL 2012
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