Durable Power Of Attorney For Health Care Form (Dpoah) Page 2
Download a blank fillable Durable Power Of Attorney For Health Care Form (Dpoah) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Durable Power Of Attorney For Health Care Form (Dpoah) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2I wish to be given medication which is necessary to control my pain without regard to any of
the above choices.
YES __________
NO __________
(Initials)
(Initials)
4.
I understand that in this paragraph I may write specific desires I want or don’t want, may attach
extra pages or may leave this question blank.
Under what conditions would you want the goals of medical treatment to switch from trying
to continue your life to focusing on your comfort? What will be important to you when you
are dying (comfort, no pain, family present, music, pray, be held etc.)? Do you want to indicate
a timeframe for trying treatment options?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
I hereby acknowledge that I have been provided with a disclosure statement explaining the effect
of this document. I have read and understand the information in the disclosure statement.
The original of this document will be kept at ________________________________ and the following
(Address)
persons and institutions will have copies:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
In witness to this, I sign my name this __________ day of ______________ , 20____ .
(Day)
(Month)
(Year)
Signed _________________________________________________________
(Your Name)
I declare that the principal appears to be of sound mind and free from duress at the time the
Durable Power of Attorney for Health Care is signed, and that the principal has affirmed that he or
she is aware of the nature of the document and is signing it freely and voluntarily.
Witness ______________________________________
Address ___________________________________
Witness ______________________________________
Address ___________________________________
To be completed by notary:
State of ____________________________________
County of __________________________________
The foregoing instrument was acknowledged before me this _______ day of _______ , 20___ .
(Day)
(Month)
(Year)
Notary Public/Justice of the Peace ______________________________ My commission expires: ________
Make copies of these two pages for your doctor, hospital, health care agent and family
DURABLE POWER OF ATTORNEY FOR HEALTH CARE – BACK
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal