Medical Power of Attorney Form

Introduction

This Medical Power of Attorney is made and entered into on Month Day, Year, by and between the Principal's Name,, with a primary address at Principal's Addressand Primary Agent's Name, with a primary address at Primary Agent's Address, granting authority to the Agent to make healthcare decisions on behalf of the Principal as outlined within this document.

Alternate Agent Information

If the primary agent is unable or unwilling to act on my behalf, I appoint:

Scope of Authority

I authorize my agent to make healthcare decisions for me, including but not limited to consenting to or refusing medical treatment, accessing my medical records, and determining my care plan if I am unable to communicate or make these decisions myself.

Effective Date and Duration

This power of attorney becomes effective immediately upon my incapacity and remains in effect until I regain the capacity to make medical decisions or until I revoke this authority in writing.

Signature

By signing below, I acknowledge that I have read, understood, and voluntarily signed this Medical Power of Attorney, and I am fully aware of its implications.

Principal Name: Date:

Witness 1 Name: Date:

Witness 2 Name: Date:

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