Form Section 1

Healthcare Power of Attorney

A member of our staff will contact you to go over the information you are about to provide us.

We have provided a blank area for comments at the very end.

The principal (person giving the power)

Your Address:

Do not expect to make selections about organ donation or do not resuscitate matters at this stage.

Such questions will be answered in front of the notary when you'll be executing this document.

Information about the agent(s)

First Health Care agent
Second Health Care agent (optional)
Third Health Care agent (optional)
If you listed multiple agents, indicate how they should serve
If you selected a co-agent option, do they act jointly or separately?
Form Section 2

Contact Info, Comments

Name of the person filling out the questionnaire
All answers were provided by me and I did not receive any legal advice from the staff at The Document People