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Colorado Advance Medical Directive Form 2

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This Colorado advance medical directive form provided by Colorado Advance Directives Consortium is a living will for surgical treatment.

Colorado Advance Medical Directive Form 2 Page 2
Colorado Advance Medical Directive Form 2
IV. CONSULTATION WITH OTHER
PERSONS
I authorize my healthcare providers to discuss my
condition and care with the following persons, under-
standing that these persons are not empowered to make
any decisions regarding my care, unless I have appointed
them as my Healthcare Agents under Medical Durable
Power of Attorney.
Name Relationship
V. NOTIFICATION OF OTHER PERSONS
Before withholding or withdrawal life-sustaining
procedures, my healthcare providers shall make a
reasonable effort to notify the following persons that I
am in a terminal condition or Persistent Vegetative State.
My healthcare providers have my permission to discuss
my condition with these persons. I do NOT authorize
these persons to make medical decisions on my behalf,
unless I have appointed one or more of them as my
Agent(s) under Medical Durable Power of Attorney.
Name Telephone number or email
VI. ANATOMICAL GIFTS
(Initials) I wish to donate my (check one or both)
____ organs and/or ____ tissues, if medically possible.
(Initials) I do not wish donate my organs or tissues.
VII. SIGNATURE
I execute this declaration, as my free and voluntary act,
this day of , 20 .
Declarant signature
VIII. DECLARATION OF WITNESSES
This declaration was signed by (name of Declarant)
in our presence, and we, in the presence of each other,
and at the Declarant’s request, have signed our names
below as witnesses. We declare that, at the time the
Declarant signed this declaration, we believe that he or
she was of sound mind and under no pressure or undue
influence. We did not sign the Declarant’s signature. We
are not doctors or employees of the attending doctor or
healthcare facility in which the Declarant is a patient.
We are neither creditors nor heirs of the Declarant and
have no claim against any portion of the Declarant’s
estate at the time this declaration was signed. We are at
least eighteen (18) years old and under no pressure,
undue influence, or otherwise disqualifying disability.
Signature of Witness
Printed Name
Address
Signature of Witness
Printed Name
Address
Notary Seal (optional)
State of ___________________________
County of }
SUBSCRIBED and sworn to before me by
, the Declarant,
and
and
witnesses, as the voluntary act and deed of the Declarant
this day of , 20 .
Notary Public
My commission expires:
Pursuant to Colorado Revised Statute 15-18.101–113
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Colorado Advance Medical Directive Form 2
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