Medical Durable Power of Attorney for Health Care

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					     Medical Durable Power of Attorney for Health Care

I, ____________________________________________________ HEREBY APPOINT:

Name:___________________________ Address _______________________________

Home Phone:____________________ Work Phone:____________________________

As my agent to make health care decisions for me if and when I am unable to make my own health
care decisions. This gives my agent the power to consent to giving, withholding or stopping my
health care, treatment, service or diagnostic procedure(s). My agent also has the authority to talk
with health care personnel, get information and sign form necessary to carry out those decisions. If
the person named as my agent is not available or is unable to act as my agent, then I appoint the
following person(s) to serve in the order listed below:

1.    Name:________________________              2.   Name:___________________________
      Address:______________________                  Address:_________________________
      Home Phone:__________________                   Home Phone:_____________________
      Work Phone:__________________                   Work Phone:_____________________

By this document I intend to create a Medical Durable Power of Attorney which shall take effect
upon my incapacity to make my own health care decisions and shall continue during that incapacity.
My agent shall make heath care decisions as I may direct below or as I make known to him/her in
some other way. If I have not expressed a choice about the health care in question, my agent shall
base his/her decision on what he/she believes to be in my best interest. (Some examples are listed
below. Initial any you may wish to choose, or write your own if you prefer.)

     If I am being kept alive by machines (ex. Ventilators, external heart regulators,
     kidney dialysis) or other artificial means, and it is only prolonging my dying,
     disconnect everything after ____ days.
     Do not give me CPR (Cardio-Pulmonary Resuscitation)
     If I am brain dead, stop all treatment after ___ days.
     I do not want to be put on a ventilator to breath for me unless it is temporary.
     If the only thing that is keeping me from dying is a feeding tube, I want it
     removed after ___ days.
     I do not want to be on kidney dialysis.
     Other:
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ____________

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             Medical Durable Power of Attorney for Health Care

BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE
 AND EFFECT OF THIS DOCUMENT.

I sign my name to this form on: (date) _________________________________________
   at (Address) _______________________________________________________________

_____________________________________________________________________________
         Signature of person creating Medical Durable Power of Attorney:

WITNESSES

I declare that the person who signed or acknowledged this document is personally
   known to me, that he/she signed or acknowledged this Medical Durable Power of
   Attorney in my presence, and that he/she appears to be of sound mind and under
   no duress, fraud, or undue influence. I am not the person appointed as the agent
   by this document.

  FIRST WITNESS                                            SECOND WITNESS

  _____________________________                     _____________________________
            Printed Name                                  Printed Name

  _____________________________                     _____________________________
            Address                                       Address

  _____________________________                     _____________________________
            Signature                                     Signature

  AT LEAST ONE OF THE ABOVE WITNESS MUST ALSO SIGN THE
  FOLLOWING DECLARATION.

I further declare that I am not related to the patient by blood, marriage, or
adoption, and, to the best of my knowledge, I am not entitled to any part of his/her
estate under a will now existing or by operation of law.

  Signature:____________________________      Signature:________________________