Wyoming Advance Health Care Directive Form Page 2
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7Print your full name: ______________________________________________________________________
Today’s date: _________________________ Initial that you have completed the page: ______
PART 1: POWER OF ATTORNEY FOR HEALTH CARE
PLEASE NOTE: Answering any of the following questions is optional, but the more information you
provide on this form, the better your designated agent may act on your behalf. This form is not to be used
to designate a financial power of attorney. It is for health care matters only. This form is in compliance
with Wyoming State Statute 35-22-401 through 416.
(1) Designation of agent: I designate the following person as my agent to make
health care decisions for me:
____________________________________________________________________
(name of person you choose as your agent)
____________________________________________________________________
(address)
____________________________________________________________________
(city)
(state)
(zip code)
____________________________________________________________________
(home phone)
(work phone)
(cell phone)
If I revoke my agent's authority, or if my agent is not willing, able or reasonably available to
make a health-care decision for me, I designate as my alternate agent:
____________________________________________________________________
(name of person you choose as your alternate agent)
____________________________________________________________________
(address)
____________________________________________________________________
(city)
(state)
(zip code)
____________________________________________________________________
(home phone)
(work phone)
(cell phone)
(2) Agent’s authority: My agent is authorized to make all health care decisions for
me, including decisions to provide, withhold or withdraw artificial nutrition and hydration
and all other forms of health care, except as I state here:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
(Add additional sheets if needed.)
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