Georgia Advance Directive For Health Care (Page 12 of 14) in pdf

Acceptance by Health Care Agent (Optional)

Your Health Care Agent and back-up Agents are not required by law to act for you nor is it mandatory that they

sign this document. However, their signatures provide assurances that they are willing to serve in this capacity.

I accept this appointment to serve as the Health Care Agent for _______________________.

I understand I must act in accordance with the preferences of the person I represent, as expressed in this

Georgia Advance Directive for Health Care or otherwise made known to me. I understand that this document

allows me to decide about _______________________’s medical care only while he/she cannot do so or

chooses not to do so. I understand that the person who appointed me may revoke this appointment at any time.

I certify that the signature of my agent and

back-up agent(s) is correct:

__________________________________ ____________ ___________________________

(Signature of Health Care Agent)

(Date)

(Signature of Principal)

__________________________________ ____________ ___________________________

(Signature Back-up #1)

(Date)

(Signature of Principal)

__________________________________ ____________ ___________________________

(Signature Back-up #2)

(Date)

(Signature of Principal)

Review (Optional)

It is important that you occasionally review your Georgia Advance Directive for Health Care to make sure this

document continues to reflect your treatment preferences. Indicate each time you review the document below.

If you do not review your Georgia Advance Directive for Health Care it will continue to remain in effect as

completed, unless you cancel it.

I have reviewed this Georgia Advance Directive for Health Care and confirm by my signature that this

document continues to convey my preferences as of the date specified.

Signature:_________________________________________ Date:_________________

Georgia Advance Directive For Health Care Page 12