Health Care Power of Attorney Layout
HEALTH CARE POWER OF ATTORNEY LAYOUT
I. PRINCIPAL’S INFORMATION
I, [Your Name], born on June 15, 1980, residing at [Your Company Address], hereby designate the individual named below as my agent to make medical decisions on my behalf if I am unable to make them myself.
II. AGENT’S INFORMATION
I appoint the following person as my agent:
Name: Sarah Johnson
Address: 123 Maple Street, Springfield, IL 62704
Phone Number: (555) 123-4567
Email: [email protected]
In the event that my agent is unable or unwilling to act on my behalf, I designate the following person as an alternate agent:
Name: Michael Johnson
Address: 456 Oak Avenue, Springfield, IL 62704
Phone Number: (555) 765-4321
Email: [email protected]
III. POWERS GRANTED
My agent shall have the authority to make any and all medical decisions on my behalf, including but not limited to:
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Decisions regarding medical treatments, procedures, and surgeries.
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Decisions concerning the selection of health care providers and facilities.
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Decisions regarding the provision of medication and other forms of care.
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Decisions about the continuation or withdrawal of life-sustaining treatments.
IV. LIMITATIONS ON AUTHORITY
My agent is not authorized to consent to any experimental treatments and should consult with my family before making decisions regarding end-of-life care.
V. SIGNATURES AND DATE
This document is executed on August 20, 2050.
Printed Name: [Your Name]
Printed Name: Sarah Johnson
VI. WITNESSES OR NOTARIZATION
This document was signed in the presence of the following witnesses:
Name: Emily Carter
Address: 789 Pine Lane, Springfield, IL 62704
Date: August 20, 2050
Name: John Carter
Address: 101 Birch Drive, Springfield, IL 62704
Date: August 20, 2050
Notarization (if applicable):
State of Illinois
Subscribed and sworn before me on August 20, 2050.
Printed Name of Notary Public: Lisa Green
My Commission Expires: March 15, 2055
