Document Concerning the Appointment
of Health Care Agent

I appoint ________________________ (Name) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and communicate an informed decision regarding treatment, my health care agent is authorized to:
(1) Convey to my physician my wishes concerning the withholding or removal of life support systems.
(2) Take whatever actions are necessary to ensure that my wishes are given effect.
If this person is unwilling or unable to serve as my health care agent, I appoint ______________________________ (Name) to be my alternative health care agent.

This request is made, after careful reflection, while I am of sound mind.

_______________________ (Signature)

_______________________ (Printed Name)

_________________ (Date)

This document was signed in our presence, by the above-named ______________________ (Name) who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed.

___________________
(Witness 1)

___________________
(Printed Name)

___________________
(Address)

___________________
(Witness 2)

___________________
(Printed Name)

___________________
(Address)