Georgia Advance Directive For Health Care Page 4
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14Georgia Advance Directive for Health Care
Name: ________________________________________
Address: _______________________________________
_____________________________________________
Social Security Number: _____________________________
Date of Birth: ____________________________________
Copies of this document have been given to:
1: _____________________________________________________________________
____________________________________________________________________
(Provide complete name, address and phone number)
2: _____________________________________________________________________
____________________________________________________________________
(Provide complete name, address and phone number)
3: _____________________________________________________________________
____________________________________________________________________
(Provide complete name, address and phone number)
4: _____________________________________________________________________
____________________________________________________________________
(Provide complete name, address and phone number)
5: _____________________________________________________________________
____________________________________________________________________
(Provide complete name, address and phone number)
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Parent category: Medical