Fillable Appointment of medical treatment decision maker made under (Eastern Health Australia)

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Appointment of medical treatment decision maker made under (Eastern Health Australia)

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03/18 Page 1 of 5
Appointment of medical treatment decision maker
Appointment of
medical treatment
decision maker
made under the Medical Treatment
Planning and Decisions Act 2016 (Vic.)
Your medical treatment decision maker has legal authority to make medical treatment decisions on your
behalf, if you do not have decision-making capacity to make the decision.
Your medical treatment decision maker is the first person you list below who is reasonably available,
and willing and able to make the decision. Only adults can appoint a medical treatment decision maker.
Part 1: Personal details
Before you start, read
the checklist of steps
with this form.
You must fill in your
full name, date of
birth and address.
A phone number is
optional.
Your full name:
Date of birth: (dd/mm/yyyy)
Address:
Phone number:
Part 2: Medical treatment decision maker details
This form allows you
to appoint up to two
people. To appoint
more people, use the
long version of this
form.
I revoke any other previous appointment of a medical treatment
decision maker however described.
I appoint as my medical treatment decision maker(s):
Fill in the details of
your first medical
treatment decision
maker here.
Medical treatment decision maker 1
Full name:
Date of birth: (dd/mm/yyyy)
Address:
Phone number:
Fill in the details of
your second medical
treatment decision
maker here.
Cross out this section
if you are not
appointing a second
medical treatment
decision maker.
Medical treatment decision maker 2
Full name:
Date of birth: (dd/mm/yyyy)
Address:
Phone number:
Appointment of
medical treatment
decision maker
(cont.)
03/18 Page 2 of 5 Appointment of medical treatment decision maker
Appointment by:
(insert your full name)
Part 3: Any limitations or conditions (optional)
Cross out if not
including limitations
or conditions.
Part 4: Witnessing
You must sign in
front of two adult
witnesses.
One witness must be
a registered medical
practitioner or able to
witness affidavits. See
justice.vic.gov.au/
affidavit for list.
Neither witness can be
an appointed medical
treatment decision
maker for you.
Refer to the checklist
if someone else is
signing on your behalf.
Signature of person making this appointment (you sign here)
Each witness certifies that:
• at the time of signing the document, the person making this appointment
appears to have decision-making capacity and appears to understand the
nature and consequences of making the appointment and revoking any
previous appointment; and
• at the time of signing the document, the person making this appointment
appeared to freely and voluntarily sign the document; and
• the person signed the document in my presence and in the presence of a
second witness; and
• I am not the person’s medical treatment decision maker under this
appointment.
Witness 1 – Authorised witness
A registered medical
practitioner or
someone able to
witness affidavits
must complete this
section.
Full name of authorised witness:
Qualification of authorised witness:
Signature of authorised witness: Date: (dd/mm/yyyy)
Witness 2 – Adult witness
Another adult witness
must complete this
section.
Full name of adult witness:
Signature of adult witness: Date: (dd/mm/yyyy)
Appointment of
medical treatment
decision maker
(cont.)
03/18 Page 3 of 5 Appointment of medical treatment decision maker
Appointment of medical treatment decision maker
Appointment by:
(insert your full name)
If an interpreter is present when this document is witnessed
If an interpreter is
present at the time
the document is
witnessed, they
complete this section
immediately after the
document is
witnessed.
Name of interpreter:
If accredited with the National Accreditation Authority
NAATI number:
I am competent to interpret from English into the following language:
I provided a true and correct interpretation to facilitate the witnessing
of the document.
Signature of interpreter: Date: (dd/mm/yyyy)
Part 5: Interpreter statement
If an interpreter assisted in the preparation of this document
If an interpreter
assisted you in
preparing this
document, the
interpreter completes
this part.
Cross out Part 5 if
not relevant.
I interpreted in the following language:
When I interpreted into this language the person appeared
to understand the language used in the document.
Name of interpreter:
NAATI number (if accredited):
Signature of interpreter: Date: (dd/mm/yyyy)
Appointment of
medical treatment
decision maker
(cont.)
03/18 Page 4 of 5 Appointment of medical treatment decision maker
Appointment by:
(insert your full name)
Part 6: Statement of acceptance
Each medical treatment decision maker you appoint must read the statement of
acceptance and sign in front of an adult witness.
Medical treatment decision maker 1
Your first medical
treatment decision
maker must read this
statement of
acceptance and sign
in front of an adult
witness.
I accept my appointment as medical treatment decision maker and state that:
• I understand the obligations of an appointed medical treatment decision
maker; and
• I undertake to act in accordance with any known preferences and values
of the person making the appointment; and
• I undertake to promote the personal and social wellbeing of the person
making the appointment, having regard to the need to respect the person’s
individuality; and
• I have read and understand any advance care directive that the person has
given before, or at the same time as, this appointment.
Name of medical treatment decision maker:
Signature of medical treatment decision maker: Date: (dd/mm/yyyy)
Witness completes
this section.
I certify that I witnessed the signing of this statement of acceptance.
Name of adult witness:
Signature of adult witness: Date: (dd/mm/yyyy)
Appointment of
medical treatment
decision maker
(cont.)
03/18 Page 5 of 5 Appointment of medical treatment decision maker
Appointment of medical treatment decision maker
Appointment by:
(insert your full name)
Part 6: Statement of acceptance (cont.)
Medical treatment decision maker 2
If you appoint a
second medical
treatment decision
maker, they must
read this statement of
acceptance and sign
in front of an adult
witness.
I accept my appointment as medical treatment decision maker and state that:
• I understand the obligations of an appointed medical treatment decision
maker; and
• I undertake to act in accordance with any known preferences and values
of the person making the appointment; and
• I undertake to promote the personal and social wellbeing of the person
making the appointment, having regard to the need to respect the person’s
individuality; and
• I have read and understand any advance care directive that the person has
given before, or at the same time as, this appointment.
Name of medical treatment decision maker:
Signature of medical treatment decision maker: Date: (dd/mm/yyyy)
Witness completes
this section.
I certify that I witnessed the signing of this statement of acceptance.
Name of adult witness:
Signature of adult witness: Date: (dd/mm/yyyy)
You have reached the end of this form.
• Please keep your original ‘Appointment of medical treatment decision maker’ form safe
and accessible for when it is needed.
• It is recommended your medical treatment decision maker has read and understood the
contents of your advance care directive (if any).
• Your ‘Appointment of medical treatment decision maker’ form and advance care directive
can be uploaded on MyHealth Record and it is recommended copies be shared with your
appointed medical treatment decision maker and relevant health practitioner(s) / health
service(s).
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Appointment of medical treatment decision maker made under (Eastern Health Australia)

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Completed 7 November 2020

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