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HEALTH CARE PROXY In the event that the

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HEALTH CARE PROXY
(________________________)
In the event that the time comes and I am incapacitated to the point that I am no longer able to
actively take part in decisions for my own life, and I am unable to direct my healthcare physician
as to my own medical care, I hereby authorize this document as my Health Care Proxy to stand as
a testament of my wishes.
I, ________________________, residing at ________________________,
________________________ in the County of ________________________ in the State of
________________________ in the zip code ________________________ and whose telephone
number is ________________________, being of sound mind, of the age of consent and acting
willingly and without duress, fraud or undue influence, herein direct that the instructions provided
herein are to be recognized as a formal statement of my desires with regards to my health care and
medical treatment, and as such I hereby voluntarily declare and make this designation with regards
to my Health Care Proxy. These instructions and directives shall be binding upon all involved to
the fullest extent allowable by law.
DESIGNATION OF HEALTH CARE PROXY
I herein designate ________________________, residing at ________________________,
________________________, ________________________ ________________________ and
whose telephone number is ________________________, as my Proxy and agent to make any
and all healthcare decisions on my behalf should I ever be diagnosed with a terminal illness,
disease, injury, or should I become incapacitated or permanently unconscious (in a coma or
persistent vegetative condition) where I would remain permanently unable to make decisions.
HEALTH CARE PROXY'S AUTHORITY COMMENCEMENT
My Proxy's authority shall become effective upon my primary or attending physician's
determination that I lack the capacity to make my own healthcare decisions, unless otherwise
stipulated below.
PROXY'S GENERAL POWERS
My Health Care Proxy shall have the power to make healthcare and medical treatment decisions
on my behalf if my attending and/or primary physician makes the determination that I am unable
to make said decisions.
LIFE-SUSTAINING MEDICAL TREATMENT
Should any of the aforementioned events occur, I wish to leave the following directives regarding
the treatment and procedures which may be used, withheld or withdrawn:
- I wish to ________________________ cardiac resuscitation (CPR) in an attempt to try
and prolong my life.
- I wish to ________________________ life-support (e.g., respirators, ventilators) used in
an effort to replace or support my natural breathing.
- I wish to ________________________ tube feeding or any other artificial or invasive
form of nutrition (food) or hydration (water).
- I wish to ________________________ blood or blood products.
- I wish to ________________________ any form of surgery or invasive diagnostic tests.
- I wish to ________________________ kidney dialysis.
- I wish to ________________________ antibiotics or medication in an attempt to try and
prolong my life.
- I wish to ________________________ maximum pain relief medication.
I understand that if I do not specifically indicate my preferences above regarding any of the forms
of treatment, I may be subjected to that form of treatment.
DECLARANT STATEMENT AND SIGNATURE
This instrument shall be governed by the laws of ________________________, and I respectfully
request that it be honored in any state in which I may reside at the time that this Health Care Proxy
shall take effect.
By signing below, I certify that I am fully aware and completely understand the contents of this
document, and that I am of sound body and mind. Furthermore, I am of the legal age of consent
and not under undue influence, fraud or duress.
WITNESSES
This Health Care Proxy must be signed by two adult witnesses that are personally present when I
sign this document.
WITNESS STATEMENT
I certify that I am of 18 years of age or older and that I know the Declarant personally or have been
provided with valid identification to his/her identity and believe him/her to be of sound mind and
under no duress, fraud or undue influence. The Declarant has had the opportunity to read this
document and has signed or acknowledged his/her signature or mark in my presence.
Under penalty of perjury I declare that I am not related to the Declarant by blood, marriage or
adoption, nor am I responsible for his/her medical care or costs. Furthermore, I am not the primary
or attending physician or an employee of the physician or other health care provider or current care
facility for the Declarant. I also attest that I am not an employee of any life or health insurance
provider, nor am I involved with the direct physical care of the Declarant. Further, I have no claim
to the Declarant's estate, and to the best of my knowledge, I am not entitled to any part of the
Declarant's estate upon his/her death with any will now in existence or by any other process of
law.
(Declarant Signature)
(Date)
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NOTARY PUBLIC
CERTIFICATE OF ACKNOWLEDGMENT
STATE OF ________________________
)
)
COUNTY OF ________________________
)
On this date, ____________________, the Declarant, ________________________, personally
appeared before me and having provided verifiable identification to be the Declarant whose name
is subscribed to this instrument and acknowledged to me that s/he executed the same in his/her
capacity, and that by his/her signature on the instrument, executed the instrument.
I declare that s/he appears to be of sound mind and not under or subject to duress, fraud or undue
influence, that s/he acknowledges the execution the same to be his/her voluntary act and deed, and
that I am not the proxy, attorney-in-fact, proxy, surrogate, or a successor of any such, as designated
within this document, nor do I hold any interest in his/her estate through a Will or by any other
means or process of law.
WITNESS my hand and seal.
____________________________________________________
(Notary Signature)
My Commission Expires: _______________________________
(Date)
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Completed 26 February 2022

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