Vermont Advance Directive For Health Care Page 8
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8ADVANCE DIRECTIVE, PAGE 6
NAME _________________________________________________________________________ DOB ______________________ DATE __________________
The following have a copy of my Advance Directive (please check):
Vermont Advance Directive Registry
Date registered:
________________________________________________________
Health care agent
Alternate health care agent
Doctor/Provider(s):
_____________________________________________________________________________________________________
Hospital(s):
_______________________________________________________________________________________________________________
Family Member(s): Please list:
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
Other:
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
NAME ________________________________________________________________________________________________________________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
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