Health Proxy Authorization Form
Please complete this form to authorize a health proxy to make medical decisions on your behalf.
Full Name of Patient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Full Name of Health Proxy
*
First Name
Last Name
Relationship to Patient
*
Contact Phone Number of Health Proxy
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of Health Proxy
*
example@example.com
Please specify the extent of authorization granted to the health proxy.
*
Signature of Patient
*
Date of Authorization
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: