HEALTH CARE PROXY
I, Name, hereby appoint Agent whose address is address and telephone number is Telephone as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect when and if I become unable to make my own health care decisions.
(2) Optional instructions: I direct my agent to make health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows.
Desires
I direct my agent to make health care decisions in accordance with my wishes and instructions as stated above or as otherwise known to him or her. I also direct my agent to abide by any limitations on his or her authority as stated above or as otherwise known to him or her.
(3) Name of substitute or fill-in agent if the person I appoint above is unable, unwilling or unavailable to act as my health care agent.
Alternate and whose address is Alternateaddress and telephone number is AlternateTelephone.
(4) Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or condition stated below:
Expiration
(5) Signature:
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Name
___________________________________________________
(address)
___________________________________________________
(Date)
Statement by Witnesses (must be 18 or older)
I declare that Name, the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence.
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Witness Number One
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Home address
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Telephone Number
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Witness Number Two
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Home address
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Telephone Number