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Medical Power of Attorney Template

Prepared for:

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

Created by:

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

Principal Name:[Principal.FirstName][Principal.LastName]

DOB:

Address:[Principal.StreetAddress], [Principal.City], [Principal.State][Principal.PostalCode]

Phone #:[Principal.Phone]

Appointment of agent and alternatives

I, as the Principal, now appoint:

Name of Agent: [Agent.FirstName][Agent.LastName]

Agent’s telephone number:[Agent.Phone]

Agent’s address:[Agent.StreetAddress], [Agent.City], [Agent.State][Agent.PostalCode]

Agent’s email address:[Agent.Email]

As my Agent to make and communicate my healthcare decisions when I cannot because I lack the capacity to provide informed consent or refusal of medical treatment.

This gives my Agent the power to consent to, refuse, or stop any healthcare, treatment, service, or procedure, except to the extent I limit those decisions in this document.

My Agent also has the authority to communicate with healthcare personnel, get information, and sign forms as necessary to carry out those decisions.

In the even that [Agent.FirstName][Agent.LastName] resigns, dies, or is otherwise unable or unwilling to so act, then I appoint the following person(s) to serve in the order below:

Name of Alternative Agent #1: [AlternativeAgent.FirstName][AlternativeAgent.LastName]

Agent’s telephone number: [AlternativeAgent.Phone]

Agent’s address: [AlternativeAgent.StreetAddress], [AlternativeAgent.City], [AlternativeAgent.State][AlternativeAgent.PostalCode]

Agent’s email address: [AlternativeAgent.Email]

Name of Alternative Agent #2: [AlternativeAgent2.FirstName][AlternativeAgent2.LastName]

Agent’s telephone number: [AlternativeAgent2.Phone]

Agent’s address: [AlternativeAgent2.StreetAddress], [AlternativeAgent2.City], [AlternativeAgent2.State][AlternativeAgent2.PostalCode]
Agent’s email address:[AlternativeAgent2.Email]

This durable power of attorney for health care shall take effect if I become unable to make my own health care decisions, as determined by the physician who has primary responsibility for my care and any necessary confirming determinations.

Instructions to agent

My Agent can make healthcare decisions as I direct below or as I make known to them in some other way. If my Agent does not know my wishes, they must act with my best interests in mind. I also ask that my Agent, as much as possible, ask me about decisions and make a reasonable effort to understand me and find out what I prefer.

☐ The Agent is authorized to direct that artificially provided fluids and nutrition,
such as feeding tube or intravenous infusion, be withheld or withdrawn.

☐ The Agent does not have this authority, and I direct that artificially provided
fluids and nutrition be provided to preserve my life, to the extent medically appropriate.

OPTIONAL: State any wishes for life-sustaining procedures, treatment, general care, and services, including any special needs or limitations: (fill in any special wishes here)

Limits on my agent

My Agent is authorized to make all medical decisions on my behalf, except for the following:
(Describe any desired limitations such as life-support considerations, life-prolonging care, shelter, nutrition, treatments, services, and procedures that you may wish to restrict your agent from making a decision on.)

Duration

This Medical Power of Attorney is effective from its execution and will remain in force indefinitely unless revoked. I understand I cannot revoke this document when I am considered incompetent to make my own decisions.

(If applicable initial and check) 

☐ This power of attorney shall expire on (insert number) day of (insert month), 20 (insert number)

Signatures

My signature below shows that I understand the purpose and reason for this document. By signing this document, I revoke and cancel all prior Medical Durable Powers of Attorney that I may have previously created:

[Sender.Company]
Signature
MM/DD/YYYY
[Sender.FirstName][Sender.LastName]
We, the undersigned witnesses, do at this moment 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 judgment, to be acting in sound mind, voluntarily and free from external influences, stress, duress, and undue influence.

[Sender.Company]
Signature
MM/DD/YYYY
[Sender.FirstName][Sender.LastName]
[Client.Company]
Signature
MM/DD/YYYY
[Client.FirstName][Client.LastName]

Medical Power of Attorney Template

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