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Form -  Health Care Power Of Attorney 

This free Medical Power of Attorney form can be used as sample document to complete your personalized form. The heading on this form is Power of Attorney for Health Care. You can also name it:

Medical Power of Attorney, or

Health Care Proxy Form

A quick call to your friendly local attorney can clarify what the form is called in your state or country.

Durable Power Of Attorney
General Power Of Attorney
Irrevocable Power Of Attorney
Revoke power of attorney
Real Estate Power Of Attorney
Health Care Power Of Attorney
Special Power Of Attorney

free power of attorney forms

Free Health Care Power Of Attorney Form

For A Quick Clean Print Version - Click Here

Power of Attorney for Health Care

I, the undersigned

(Full legal name) ______________________________

(Identity number) ______________________________ residing at

(Address) ____________________________________

               ____________________________________

revoke any and all previous Power of Attorney for Health Care made by me and appoint

(Full legal name) ________________________________

(Identity number) ______________________________ residing at

(Address) ____________________________________

                ____________________________________

to be my Agent for my health and personal care.

If my Agent is unable or unwilling to serve, I appoint

(Full legal name) ________________________________

(Identity number) ______________________________ residing at

(Address) ____________________________________

                ____________________________________

as substitute agent for my health and personal care.

1. I direct my Agent to make health care decisions according to my wishes as set out in my Health Care Directive (Living Will) attached hereto.

2. I further authorize my Agent to make personal care decisions for me if I am mentally unable to do so.

3. This Power of Attorney for Health Care shall take effect when I become unable to make my own health care decisions and it shall remain in full force and effect until my death unless I revoke it.

Executed this ______ day of __________________20 ____

at ______________________________________

Signature: ________________________________

in the presence of the undersigned witnesses:

Declaration of Witnesses

As witnesses we declare that the above named person is personally known to us, appears to be of sound mind and signed this directive willingly and free of undue influence or duress. We are legal adults and are not related to him / her by blood, marriage or adoption and are not appointed as agents in this directive. To our knowledge we are not beneficiaries of his / her estate and have no claims against his / her estate. We are not directly involved in his / her health care. We declare that he / she signed this will in our presence as we signed as witnesses in the presence of each other, all being present at the same time. Under penalty of perjury we declare these statements to be true and correct on this ___________________ day of ____________________ 20____ at _________________________________.

Witness 1.    

Name: ______________________

Address: _____________________________________________

Signature: ________________________

Witness 2.    

Name: ______________________

Address: _____________________________________________

Signature: ________________________ 

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