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Health Care Power of Attorney
This is an important legal document. This document designates the person you want to make medical decisions for you in the event you
are unable to participate in your own medical decisions.
Fill out this document carefully. You may want to seek professional help to make sure the form does what you intend and is completed
This document will be in effect until you revoke it. Read this document from time to time to make sure it still reflects your wishes. You
may change or revoke this document at any time by telling your doctor and other healthcare providers. You should give copies of this
document to your doctor and family. This form is optional. If you choose to use this form, the form has signature lines for you and
either two witnesses, or a notary.
1. Designation of Health Care Agent:
I, ____________________________ hereby appoint: ________________________________________________________
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