I, residing at (the "Principal"), appoint residing at as my agent (the "Agent") to make healthcare decisions on my behalf, in my stead, and for benefit, in any lawful way, if I am unable to make or communicate these decisions myself, including decisions regarding medical treatment, surgery, medication, and other healthcare-related matters.
If the Agent named in this Medical Power of Attorney is unable or unwilling to make decisions for me, I designate the following individual as an alternate Agent:
residing at .
My Agent is authorized to:
Life-sustaining treatment: In the event of a medical condition where my attending physician determines that my condition is terminal or that I am in a permanent unconscious state with no reasonable hope of recovery, I express the following preferences regarding life-sustaining treatment:
Effective date. This Medical Power of Attorney shall become effective immediately upon my incapacitation.
Duration. This Medical Power of Attorney shall remain in effect unless revoked by me in writing or upon my death.
Revocation. I have the right to revoke this Medical Power of Attorney at any time by providing written notification to my Agent and healthcare providers or by any other means in accordance with applicable laws.
I declare that I am of sound mind, and I am signing this document voluntarily. I understand its purpose and significance.
IN WITNESS THEREOF, this Power of Attorney is executed on .
Principal
Signature: _____________
Full name:
Address:
Witness 1
Signature: _____________
Full name:
Address:
Witness 2
Signature: _____________
Full name:
Address:
Notary Acknowledgment
Sworn to and subscribed before me on .
____________________
Notary public's name and seal