Spousal Affidavit

I, [Your Name], residing at [Your Address], being of sound mind and body, do hereby solemnly affirm and declare the following under penalty of perjury:

1. I am the lawful spouse of [Spouse's Name], who is currently incapacitated and unable to make decisions regarding their medical treatment.

2. I hereby authorize and empower [Hospital Name], located at [Hospital Address], or any other qualified medical personnel involved in the care of my spouse, to administer any necessary medical treatment or procedures deemed necessary for the health and well-being of my spouse.

3. I understand that this authorization encompasses any medical interventions, surgeries, medications, or therapies that the attending medical professionals deem necessary for the proper treatment of my spouse's condition.

4. I acknowledge that this authorization is given with the full understanding that it may be necessary to make decisions swiftly in emergency situations to safeguard the life and health of my spouse.

5. I agree to indemnify and hold harmless [Hospital Name], its employees, agents, and representatives, from any and all claims, liabilities, or damages arising out of or related to the medical treatment provided to my spouse based on this authorization, except in cases of gross negligence or willful misconduct.

I affirm that I am the lawful spouse of [Spouse's Name], and I have the legal authority to make medical decisions on their behalf in accordance with applicable laws and regulations.

This affidavit is made voluntarily and without any undue influence or coercion.

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SUBSCRIBED AND SWORN to before me this [Date], at the [Notary Public Address], affiant exhibiting to me his/her [ID Presented] as his/her competent evidence of identity.

[Notary Public Seal]

NOTARY PUBLIC

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