Health Care Proxy Form
Law Governing State
Name of Principal
First Name
Middle Name
Last Name
Suffix
Address of Principal
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Primary Agent
First Name
Middle Name
Last Name
Suffix
Address of Primary Agent
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Do you wish to appoint an alternate agent?
Yes
No
Alternate Agent Paragraph Placeholder
In the event that the agent appointed above becomes unavailable or is unwilling to perform the duty reposed, I hereby appoint as alternate:
Alternate Agent Paragraph Container
Name of Alternate Agent
First Name
Middle Name
Last Name
Suffix
Address of Alternate Agent
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Limitations to Medical Decisions
Any restriction or prohibition that the Agent cannot perform on behalf of the Principal
Effectivity Start
Upon Mental Disability or incapacity of the Principal to make decisions for his/her own health
Immediately
Effectivity End
Upon death of the principal, unless powers is granted to Agent post-death authority provided in this power of attorney superseding this limitation.
On a specific date provided
Upon revocation of the Principal of this document
Date
-
Month
-
Day
Year
Date
Organ Donation
In case of my death, I hereby offer any organs and tissues as gift to anyone who shall make benefit such.
I will not donate any par of my organ or skin after my death.
Signature of Principal
Clear
Date
-
Month
-
Day
Year
Date
Signature of Agent
Clear
Date
-
Month
-
Day
Year
Date
Signature of Alternate Agent
Clear
Date
-
Month
-
Day
Year
Date
Name of First Witness
First Name
Last Name
Signature
Clear
Date
-
Month
-
Day
Year
Date
Name of Second Witness
First Name
Last Name
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: