Durable Power Of Attorney For Health Care - State Of Georgia Page 6
ADVERTISEMENT
1
2
3
4
5
6
78.
Duration and Revocation: It is my understanding and intention that unless I revoke this proxy and
directive, it will remain in effect indefinitely. My signature on this document shall be deemed to constitute a
revocation of any prior health care proxy, directive or other similar document I may have executed prior to
today's date.
My
Signature:
Signature
_______________________________________________________
(If you are not physically capable of signing, please ask another
person to sign your name on your behalf.)
Print Name:
_______________________________________________________
Date:
_______________________________________________________
Address:
_______________________________________________________
Telephone: Day:
Evening:
_____________________________
______________________
DECLARATION OF WITNESSES
I, being over 18 years of age, declare that the person who signed (or asked another to sign) this document is
personally known to me and appears to be of sound mind and acting willingly and free from duress. He/She
signed (or asked another to sign for him/her) this document in my presence (and that person signed in my
presence) and in the presence of the other witness.
Witnesse
Witness 1:
s
__________________________________________________________
Residing at:
__________________________________________________________
Witness 2:
__________________________________________________________
Residing at:
__________________________________________________________
ONLY IF YOU ARE SIGNING THIS DOCUMENT IN A HOSPITAL OR A SKILLED NURSING
FACILITY, YOUR ATTENDING PHYSICIAN MUST SIGN BELOW.
ATTENDING PHYSICIAN ATTESTATION
I, on this___________ day of __________, 200__, hereby witness this Durable Power of Attorney for Health
Care and attest that I believe the person who signed (or asked another to sign) this document to be of sound
mind and to have made this Durable Power of Attorney for Health Care willingly and voluntarily.
Attendin
Signature:
g
__________________________________________________________
Physician
Residing at:
__________________________________________________________
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal