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Health Care Proxy
(1) I,
___________________________ hereby
appoint _________________________________ as my health
care agent to make any and all health care decisions for me, except to the
extent that I state otherwise. This proxy shall take effect when and if I
become unable to make my own health care decisions.
(2) Optional instructions: I direct my agent to make health care
decisions in accord with my wishes and limitations as stated below, or as he
or she otherwise knows. (Attach additional pages if necessary.)
____________________________________ ____________________________________
____________________________________(Unless your
agent knows your wishes about artificial nutrition and hydration [feeding
tubes], your agent will not be allowed to make decisions about artificial
nutrition and hydration. See instructions on reverse for samples of language
you could use.)
(3) Name of substitute or fill-in agent if the person I appoint above
is unable, unwilling or unavailable to act as my health care agent.
_____________________________________ _____________________________________
(4) Unless I revoke it, this proxy shall remain in effect indefinitely,
or until the date or conditions stated below. This proxy shall expire
(specific date or conditions, if desired):
_____________________________________
(5) Signature ________________________
Address _____________________________
Date ________________________________
Statement by Witnesses (must be 18 or older) I declare that the person who
signed this document is personally known to me and appears to be of sound mind
and acting of his or her own free will. He or she signed (or asked another to
sign for him or her) this document in my presence.
Witness 1 _____________________________
Address ______________________________
Witness 2 _____________________________
Address ______________________________
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