Medical Health Care Proxy
The primary physician of ________________________________ has
advised the following “interested parties” who (patient
name)
may include a spouse, parent, adult children,
brother or sister, grandchildren or close friend(s),
that _______________________________________ lacks
decisional capacity in matters of personal health care
(patient
name)
and so is not able to give informed consent to or
refusal of medical treatment, use of cardio-pulmonary resuscitation or the administration
of artificial nourishment or hydration to prolong the act of dying.
By
consensus, the undersigned agree that
_______________________________________________ should act as
(Designated
Proxy Decision Maker)
Proxy Decision Maker for _______________________________________
with respect to any and all decisions
(patient
name)
without
limitations with respect to termination or withholding of life support in
accordance with the authority set forth under
____________________________________________________________________________________________
Signature Date Relationship
____________________________________________________________________________________________________________________
Signature Date Relationship
____________________________________________________________________________________________
Signature Date Relationship
____________________________________________________________________________________________
Signature Date Relationship
The
foregoing instrument was signed and declared by
______________________________as his/her voluntary act.
(Designated
Proxy Decision Maker)
on this ___________ day of ___________________,
20_____.
State
of
County
of ____________________________
Witness
my hand and seal Notary
Public ______________________________________________
My
Commission expires: Address
__________________________________________________
Each medical institution has an
individually designed Medical Health Care Proxy Form.
An individual may have to sign a separate
form for each
health care institution, such as a hospital, nursing home, or hospice
if the patient receives care in more than one institution.