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Medical Power of Attorney

Prepared for:

[Client.FirstName][Client.LastName]
[Client.Company]

Created by:

[Sender.FirstName][Sender.LastName]
[Sender.Company]

KNOW ALL MEN BY THESE PRESENTS, THAT I, [PRINCIPAL.FirstName][PRINCIPAL.LastName] (“the Principal”), holder of [PRINCIPAL ID DOCUMENT] number [PRINCIPAL ID NUMBER] and residing at [PRINCIPAL ADDRESS] do hereby make and appoint as my lawful attorney for me and in my place and in my stead [ATTORNEY NAME] (“the Attorney”), holder of [ATTORNEY ID DOCUMENT] number [ATTORNEY ID NUMBER] and residing at [ATTORNEY ADDRESS] empowering him/her to do all of the following and do hereby ratify and endorse all those things which my true and lawful attorney may do or cause to be done:

To exercise any and all of the following listed powers in my place and in my stead in the event that I become unable or unfit to make decisions about my own health care and that this fact is certified in writing by a competent practising physician:

  1. Request, receive and review any and all documents relating to my physical and mental health including but not limited to medical information, medical and hospital records, commitment papers, discharge papers, medical notes and test results for whatever reason the Attorney may see fit and to share these documents and their contents with any third party as the Attorney may in their absolute discretion see fit.
  2. To discuss freely and fully with any third party including any medical practitioner or representative of any hospital or medical practice the particulars of my medical case.
  3. To attend to any formalities whatsoever that the Attorney considers are necessary or conducive to the request of the information listed above including the execution on my behalf of request forms and the application to a competent Court or medical authority in my stead.
  4. To request, authorise, instruct and consent to any and all medical treatments including but not limited to invasive and experimental treatments that the Attorney shall in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
  5. To instruct a change of physician or physicians, treatment or treatments, hospital or medical practice for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
  6. To instruct the transfer of the Principal to another place of treatment or to remove and to discharge the Principal from any place of treatment for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.
  7. To instruct the withdrawal or cessation of any and all medical treatments for whatever reason the Attorney may in their absolute discretion see fit and without any obligation to give reasons or justification and regardless that the decision may be contrary to medical advice.

This Medical Power of Attorney shall be effective from the date of its execution and shall remain in force indefinitely unless revoked.

Signed this [DAY] of [MONTH], [YEAR] in the presence of two independent witnesses.

[PRINCIPAL.FirstName][PRINCIPAL.LastName]

Signature


We, the undersigned witnesses, do hereby declare under penalty of perjury that we have witnessed the Principal whose name, identity and handwriting are known to us signing and executing this Medical Power of Attorney in our presence. Further we declare that we are not related to the Principal by blood nor by marriage nor by adoption nor are we involved in providing medical treatment to the Principal nor are we beneficiaries under the Principal’s Last Will and Testament and that the Principal appears, in our best judgement, to be acting in sound mind, voluntarily and free from external influences, stress, duress and undue influence.

[WITNESS 1.FirstName][WITNESS 1.LastName]
[WITNESS 1 ADDRESS]

Signature


[WITNESS 2.FirstName][WITNESS 2.LastName]
[WITNESS 2 ADDRESS]

Signature


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