Virginia Advance Directive For Health Care With Special Provisions For Mental Health Conditions Form Page 4

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3. I provide the following other instructions concerning my health care:

[YOU MAY WRITE HERE STATEMENTS AND INSTRUCTIONS ABOUT TREATMENTS THAT YOU

DO WANT, IF MEDICALLY APPROPRIATE, OR ABOUT TREATMENTS YOU DO NOT WANT

UNDER SPECIFIC CIRCUMSTANCES OR ANY CIRCUMSTANCES. IT IS IMPORTANT THAT YOUR

INSTRUCTIONS HERE DO NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS

ADVANCE DIRECTIVE.]

______________________________________________________________________________________________________

4. [INSTEAD OF WRITING INSTRUCTIONS ON THIS FORM, YOU MAY DIRECT THAT YOUR MENTAL

HEALTH CARE BE PROVIDED IN ACCORDANCE WITH A CRISIS PLAN. IF YOU HAVE PREPARED A

CRISIS PLAN, CHECK THE FOLLOWING BOX AND ATTACH THE CRISIS PLAN TO THIS DOCUMENT.]

p I direct that my mental health care be provided in conformity with the preferences I have expressed in the

accompanying crisis plan to the extent authorized by law.

SECTION III: ANATOMICAL GIFTS

(YOU MAY USE THIS DOCUMENT TO RECORD YOUR DECISION TO DONATE YOUR ORGANS, EYES

AND TISSUES OR YOUR WHOLE BODY AFTER YOUR DEATH. IF YOU DO NOT MAKE THIS DECISION

HERE OR IN ANY OTHER DOCUMENT, YOUR AGENT CAN MAKE THE DECISION FOR YOU UNLESS

YOU SPECIFICALLY PROHIBIT HIM/HER FROM DOING SO, WHICH YOU MAY DO IN THIS OR SOME

OTHER DOCUMENT. CHECK ONE OF THE BOXES BELOW IF YOU WISH TO USE THIS SECTION TO

MAKE YOUR DONATION DECISION.)

p I donate my organs, eyes and tissues for use in transplantation, therapy, research and education. I direct that all

necessary measures be taken to ensure the medical suitability of my organs, eyes or tissues for donation. I understand

that I may register my directions at the Department of Motor Vehicles or directly on the donor registry, www.

, and that I may use the donor registry to amend or revoke my directions; OR

p I donate my whole body for research and education.

[Write here any specific instructions you wish to give about anatomical gifts.]

______________________________________________________________________________________________________

AFFIRMATION AND RIGHT TO REVOKE:

By signing below, I indicate that I understand this document and that

I am willingly and voluntarily executing it. I also understand that I may revoke all or any part of it at any time as provided by

law.

___________________________________________________________________________________________________________

Date

Signature of Declarant

The declarant signed the foregoing advance directive in my presence. [TWO ADULT WITNESSES NEEDED]

______________________________________________________ ____________________________________________________

Witness Signature

Witness Printed

______________________________________________________ ____________________________________________________

Witness Signature

Witness Printed

This form satisfies the requirements of Virginia's Health Care Decisions Act. If you have legal questions about this form or would like to develop a

different form to meet your particular needs, you should talk with an attorney. It is your responsibility to provide a copy of your advance directive to

your treating physician. You also should provide copies to your agent, close relatives and/or friends. For information on storing this advance directive in

the free Virginia Advance Health Directive Registry, go to This form is provided by the Virginia Hospital & Healthcare

Association as a service to its members and the public. (June 2012, ) seg

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