Wyoming Advance Health Care Directive Form Page 6
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7Print your full name: ______________________________________________________________________
Today’s date: _________________________ Initial that you have completed the page: ______
PART 4: INFORMATION ABOUT MY HEALTH CARE PROVIDER
(10) The following physician is my primary physician:
______________________________________________________________________
(name of physician)
______________________________________________________________________
(address)
______________________________________________________________________
(city)
(state) (zip code)
______________________________________________________________________
(phone)
More information about my health care can be obtained through:
______________________________________________________________________
(name of health care institution/hospice)
______________________________________________________________________
(address)
______________________________________________________________________
(city)
(state) (zip code)
______________________________________________________________________
(phone)
(11) Effect of copy: A copy of this form has the same effect as the original.
SIGNATURE
(Sign and date the form here):
______________________________________________________________________
(print your name)
______________________________________________________________________
(sign your name)
(date)
______________________________________________________________________
(address)
______________________________________________________________________
(city)
(state) (zip code)
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Parent category: Medical