Item (1) Write the name, home address and
telephone number of the person you are selecting as your agent.
Item (2) If you want to appoint an alternate
agent, write the name, home address and telephone number of the
person you are selecting as your alternate agent.
Item (3) Your Health Care Proxy will remain
valid indefinitely unless you set an expiration date or condition
for its expiration. This section is optional and should be filled
in only if you want your Health Care Proxy to expire.
Item (4) If you have special instructions for
your agent, write them here. Also, if you wish to limit your
agent's authority in any way, you may say so here or discuss them
with your health care agent. If you do not state any limitations,
your agent will be allowed to make all health care decisions that
you could have made, including the decision to consent to or refuse
If you want to give your agent broad authority, you may do so
right on the form. Simply write:
I have discussed my wishes with my health care agent and
alternate and they know my wishes including those about artificial
nutrition and hydration.
If you wish to make more specific instructions, you could
If I become terminally ill, I do/don't want to receive the
following types of treatments....
If I am in a coma or have little conscious understanding,
with no hope of recovery, then I do/ don't want the following types
If I have brain damage or a brain disease that makes me
unable to recognize people or speak and there is no hope that my
condition will improve, I do/don't want the following types of
I have discussed with my agent my wishes about _______ and I
want my agent to make all decisions about these measures.
Examples of medical treatments about which you may wish to give
your agent special instructions are listed below. This is not a
- artificial respiration
- artificial nutrition and hydration (nourishment and water
provided by feeding tube)
- cardiopulmonary resuscitation (CPR)
- antipsychotic medication
- electric shock therapy
- surgical procedures
- blood transfusions
Item (5) You must date and sign this Health
Care Proxy form. If you are unable to sign yourself, you may direct
someone else to sign in your presence. Be sure to include your
Item (6) You may state wishes or instructions
about organ and/or tissue donation on this form. A health care
agent cannot make a decision about organ and/or tissue donation
because the agent's authority ends upon your death. The law does
provide for certain individuals in order of priority to consent to
an organ and/or tissue donation on your behalf: your spouse, a son
or daughter 18 years of age or older, either of your parents, a
brother or sister 18 years of age or older, a guardian appointed by
a court prior to the donor's death, or any other legally authorized
Item (7) Two witnesses 18 years of age or older
must sign this Health Care Proxy form. The person who is appointed
your agent or alternate agent cannot sign as a witness.
Download a Health Care
Proxy form today.