Your Full Name:
Your Complete Mailing Address:
Your Telephone Number: (include area code)
Your Primary Email Address:
How You Wish To Be Contacted:
Your Primary Agent For Health Care:
OPTIONAL: 1st Alternate Agent For Health Care:
Optional: 2nd Alternate Agent For Health Care:
OPTIONAL: Limits On Your Agent's Authority:
OPTIONAL: When Your Agent's Authority Becomes Effective: (If you enter your initials in this box, your agent's authority becomes effective immediately after you execute your instrument. This is the RECOMMENDED choice. If you leave this box blank, your agent's authority only becomes effective once your Primary Care Provider, whom you will have a chance to designate below, certifies that you have become unable to communicate or incompetent. This can be a cumbersome process and could put you at risk and may defeat the purposes of creating your instrument. Even if you give your agent immediate authority, medical providers will act on your instructions whenever you are competent and can communicate.)
Your End-of-Life Choice:
OPTIONAL: Artifical Nutrition, Hydration and Ventilation: Artificial Nutrition, hydration and ventilation must be provided, withheld or withdraw in accordance with the choice I have made immediately above unless I include my initials in this box.
OPTIONAL: Limits on Artificial Nutrition, Hydration and Ventilation: If I entered my initials in the box above, artificial nutrition, hydration and ventilation must be provided regardless of my condition and regardless of my End-of-Life decision above, unless I further limit my choice by checking one of these boxes:
My Pain Relief or Discomfort Choice:
(If I have chosen [a], I want full pain relief even if the amount needed to relieve my pain may hasten my death. I do not want to suffer. If I have chosen [b], I want pain relief treatment up to the level that my Primary Care Provider decides would raise a serious risk to hasten my death.)
OPTIONAL: My Other Wishes: (If you do not agree with any of the optional choices above and wish to write your own directions, or if you wish to add to any of the instructions above, you may do so in this box.)
My Choice Respecting Organ Donation: Upon my death, my choice respecting donation of my organs, tissues and body parts is indicated here. The decision(s) I make here and below supersede any decisions I have previously made, including choices on my driver's license.
OPTIONAL: If your choice was (a)above, you can skip this box and the next two boxes. However, if your choice was (b) above, you can use this box to further describe your decision. (An unrestricted gift means that ANY or ALL of your organs, tissues or body parts, including your entire body, can be used as needed for any purpose.)
OPTIONAL: If your choice above was (a)immediately above, you can skip this box and the next. However, if your choice was (b), you can use this box and the next to further limit your gift(s). I will donate only my organs, tissues or body parts I have listed in this box.
OPTIONAL: The organs, tissues and/or body parts I have opted to donate upon my death can only be used for the following purposes. (You may check as many as you wish.)
OPTIONAL: Designation Of My Primary Care Provider. (If you designate a PCP, please enter on separate lines the following: Provider's Full Name; Provider's Medical Designation (MD, DO, DC, PA, NP, etc.);Provider's office street address;City, State and Zip Code;>br>Office Telephone Number with Area Code.
OPTIONAL: Designation of Alternate Care Provider. (If you designate an ACP, please enter all the information requested for your PCP. Youn may simply state: any partner or associate of my PCP, who is covering for my PCP.)
Your Witnesses: If you will not be executing your Advance Health Care Directive at my office, please enter on separate lines the following information for each of your TWO (2) required witnesses: Full Name;
Street Address; City, State and Zip Code. (If you will be coming to my office to execute your AHCD, I will provide the necessary witnesses.)
TYPE OF JURISDICTION: Select from the list the type of jurisdiction in which you reside:
NAME OF YOUR STATE, COMMONWEALTH, ETC.
TYPE OF YOUR POLITICAL SUBDIVISION: select from the list the type of political subdivision in which you reside:
NAME OF YOUR COUNTY OR PARISH:
MONTH AND YEAR OF SIGNING: Enter the month and year you will be signing your Advance Health Care Directive in the following format: November, 2006