Power Of Attorney For Health Care - Sage Medical Group (Page 3 of 3) in pdf

Power Of Attorney For Health Care - Sage Medical Group Page 3

Illinois Statutory Short Form Power of Attorney for Health Care

Page 3

(If you wish to name your agent as guardian of your person, in the event a court decides that one should be

appointed, you may, but are not required to, do so by retaining the following paragraph. The court will appoint

your agent if the court finds that such appointment will serve your best interests and welfare. Strike out paragraph

6 if you do not want your agent to act as guardian.)

6. If a guardian of my person is to be appointed, I nominate the agent acting under this power of attorney as such guard-

ian, to serve without bond or security.

7. I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my

agent.

Signed ____________________________________________________________________________________________

(principal)

The principal has had an opportunity to read the above form and has signed the form or acknowledged his or her signature

or mark on the form in my presence.

____________________________________________ Residing at ___________________________________________

(witness)

(You may, but are not required to, request your agent and successor agents to provide specimen signatures below. If you

include specimen signatures in this power of attorney, you must complete the certification opposite the signatures of the

agents.)

Specimen signatures of agent (and successors)

I certify that the signatures of my agent (and successors)

are correct.

_________________________________________

_____________________________________________

(agent)

(principal)

_________________________________________

_____________________________________________

(successor agent)

(principal)

_________________________________________

_____________________________________________

(successor agent)

(principal)

Power Of Attorney For Health Care - Sage Medical Group Page 3