Advance Health Care Directive Form Page 4
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5ADVANCE HEALTH CARE DIRECTIVE FORM
PAGE 4 of 5
PART 4
PRIMARY PHYSICIAN
(OPTIONAL)
(4.1)
I designate the following physician as my primary physician:
(name of physician)
(address)
(city)
(state)
(ZIP Code)
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary
physician, I designate the following physician as my primary physician:
(name of physician)
(address)
(city)
(state)
(ZIP Code)
(phone)
PART 5
(5.1)
EFFECT OF COPY: A copy of this form has the same effect as the original.
(5.2)
SIGNATURE: Sign and date the form here:
(print your name)
(sign your name)
(date)
(address)
(city)
(state)
(ZIP Code)
(5.3)
STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual
who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity
was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my
presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am
not a person appointed as agent by this advance directive, and (5) that I am not the individual's health care provider, an
employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a
community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a
residential care facility for the elderly.
First witness
Second witness
(print name)
(print name)
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