POWER OF ATTORNEY - HEALTH CARE
The undersigned_________________________________ of_______________________
County, State of_______________________________, does hereby make, constitute and appoint
___________________________________________________________ of ________________________
County, State of ___________________, the undersigned’s true and lawful Attorney-in-Fact, with
full right, power and authority for the undersigned and in the undersigned’s name, place and stead:
The absolute and unqualified right and power to secure for the undersigned, medical care and
attention, including but not limited to the employment of physicians, surgeons, health care
practitioners, hospitals and any other form of medical care on behalf of the undersigned whether in
the United States of America or outside of the United States of America, and that this grant of power
is given unto my above-named Attorney-in-Fact and that said grant of power is absolute and
unqualified to secure medical attention and care for the undersigned, without reservation, and I give
and grant in the discretion of said Attorney-in-Fact, permission to obtain any medical care that may
be required for me, whatsoever, without limitation and whether said medical care is occasioned by
reason of illness or injury to the undersigned.
Giving and granting unto said Attorney-in-Fact the full power and authority to do and perform each and
every act, deed, matter and thing whatsoever required and necessary to be done in and about the
foregoing, as fully as the undersigned might or could do if personally acting on my own behalf
The undersigned further directs that this Power of Attorney shall take effect immediately and shall be
irrevocable unless and until such time as there is delivered to my Attorney-in-Fact a duly acknowledged
revocation of this instrument and that the acceptance of such revocation is endorsed thereon by my Attorney-
in-Fact. This Power of Attorney shall not be affected by my disability.
Words and phrases herein, including acknowledgment hereof, shall be construed as in the singular or plural
number, and as masculine or feminine gender, according to the context.
Dated: ______________________, 200_______.
STATE OF , COUNTY OF , ss:
On this ___ day of _______, 200___, before me, the undersigned, a Notary Public in and for
said State, personally appeared _________________________________________ to me known to
be the identical person named in and who executed the foregoing instrument, and acknowledged
that he or she executed the same as their voluntary act and deed.
Notary Public in and for said State