Healthcare Power of Attorney Form

Please complete this form to designate an individual who will make medical decisions on your behalf if you become unable to do so.

Principal (Person Granting Authority):

I, Principal's Full Name

Address

Phone number

Date of Birth

Hereby designate the person named below as my agent to make healthcare decisions on my behalf:

Agent Name

Relationship

Phone number

Email

If the agent is unavailable or unable to act, I appoint the following alternate agent:

Alternate Agent's Full Name

Relationship to Principal

3. Grant of Authority:

My agent has the full authority to make healthcare decisions for me, including but not limited to:

Consent to, refuse, or withdraw consent to any medical care, treatment, service, or procedure.
Make decisions about my care, including hospitalization, surgery, medication, and life-sustaining treatment.
Access my medical records and discuss my health with my healthcare providers.
Arrange for my admission to or discharge from any medical facility, including nursing homes or hospice care.

This power is effective immediately and shall remain in effect unless revoked by me in writing.

I, the principal, sign my name to this Healthcare Power of Attorney on Date at Location, and declare that I understand the contents of this document.

Principal’s Signature:

Date:

Witness 1:

Full Name:

Signature:

State of , County of

On before me, [Notary Public's Full Name], personally appeared [Principal's Full Name], who is personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this document.

Notary Public’s Signature Principal

My commission expires: Date

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