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New Jersey Medical Power of Attorney Form


New Jersey Medical Power of Attorney Form
New Jersey Medical Power of Attorney Form
New Jersey Medical Power Of Attorney
I, __________________________________________________________________________________________________, residing at
__________________________________________________________________________________________________, as principal,
hereby designate and appoint_________________________________________________________________________, residing at
__________________________________________________________________________________________________, as my agent
for all matters relating to my health care including, but not limited to, full power to give, refuse or revoke consent to all medical,
surgical and hospital care. Specifically, I authorize my agent to order the refusal, discontinuation or withdrawal of all forms of
l
ife-sustaining treatment if my agent determines that based upon his/her knowledge of my personal instructions, beliefs, and
value system I would not want to have such treatment instituted or continued. This power of attorney shall not be affected by
any disability of the principal.
Signed, sealed and delivered in the presence of:
Agents Signature
State of New Jersey )
) ss.:
County of )
BE IT REMEMBERED THAT ON THIS _____________________ day of _________________________, 20 ______, before me the
subscriber, a Notary Public of New Jersey, personally appeared ________________________, who I am satisfied is the person
named in and who executed the within Power of Attorney and _he acknowledged that _he signed, sealed and delivered said
Power of Attorney as his/her voluntary act and deed, for the uses and purposes therein expressed.
Notary Public
Principals Signature
New Jersey Medical Power of Attorney Form