Virginia Advance Directive For Health Care With Special Provisions For Mental Health Conditions Form
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4VIRGINIA ADVANCE DIRECTIVE FOR HEALTH CARE
WITH SPECIAL PROVISIONS FOR MENTAL HEALTH CONDITIONS
I, ____________________________________________________________________________________, willingly and
voluntarily make known my wishes in the event that I am incapable of making an informed decision about my health
care, as follows:
(YOU MAY INCLUDE ANY OR ALL OF THE PROVISIONS IN SECTIONS I AND II BELOW.)
SECTION I: APPOINTMENT AND POWERS OF MY AGENT
(CROSS THROUGH THIS SECTION I IF YOU DO NOT WANT TO APPOINT AN AGENT TO MAKE
HEALTH CARE DECISIONS FOR YOU.)
A. Appointment of My Agent
I hereby appoint _________________________________________________________________________________________
Name of Primary Agent
E-mail Address
________________________________________________________________________________________________________
Home Address
Telephone Number
as my agent to make health care decisions on my behalf as authorized in this document.
If the primary agent named above is not reasonably available or is unable or unwilling to act as my agent, then I appoint
as successor agent to serve in that capacity:
Name of Successor Agent
E-mail Address
Home Address
Telephone Number
I grant to my agent full authority to make health care decisions on my behalf as described below. My agent shall have
this authority whenever and for as long as I have been determined to be incapable of making an informed decision.
In making health care decisions on my behalf, I want my agent to follow my desires and preferences as stated in this
document or as otherwise known to him or her. If my agent cannot determine what health care choice I would have
made on my own behalf, then I want my agent to make a choice for me based upon what he or she believes to be in my
best interests.
B. Powers of My Agent
[IF YOU APPOINTED AN AGENT ABOVE, YOU MAY GIVE HIM/HER THE POWERS LISTED BELOW.
YOU MAY CROSS THROUGH ANY POWERS LISTED BELOW THAT YOU DO NOT WANT TO GIVE
YOUR AGENT AND ADD ANY ADDITIONAL POWERS YOU DO WANT TO GIVE YOUR AGENT.]
The powers of my agent shall include the following:
1. To consent to or refuse or withdraw consent to any type of health care, including, but not limited to, artificial
respiration (breathing machine), artificially administered nutrition (tube feeding) and hydration (IV fluids), and
cardiopulmonary resuscitation (CPR). This authorization specifically includes the power to consent to dosages of
pain-relieving medication in excess of recommended dosages in an amount sufficient to relieve pain. This applies
even if this medication carries the risk of addiction or of inadvertently hastening my death.
2. To request, receive and review any oral or written information regarding my physical or mental health, including but
not limited to medical and hospital records, and to consent to the disclosure of this information as necessary to carry
out my directions as stated in this advance directive.
3. To employ and discharge my health care providers.
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