Medical Power Of Attorney / Advanced Health Care Directive

First Name *

Last Name *

Email *

Phone *

Health Care: Do you want to appoint someone to make your health care decisions if you are unable to?

Yes

Health Care Preferences

Health Care: Do you want to list your healthcare preferences so caregivers have instruction to follow?

Yes

Location

Health Care: Which state do you live in?

Care if in Terminal Condition

A terminal condition is an incurable injury or illness that will likely result in death within the near future. Additional medical treatment will only serve to postpone the moment of death.

Artificial life support is any life-prolonging procedure that helps to restore, replace, or maintain a spontaneous and vital bodily function. For example, assistance with maintaining breathing or blood pressure.

Life support does not include medical treatment performed in a pre-hospital situation or artificially administered food/water or pain relief.

Comfort care is treatment with the sole objective of relieving pain. It may lengthen or shorten a person's life and does not include artificially administered food and water.

Health Care: Do you want all forms of medical care if your condition is terminal with no reasonable hope of recovery? This includes life support, tube feeding, and comfort care(pain relief).

Yes

Only if No selected above, Select which types of care you wish to receive:

Life Support

Tube Feeding(food and water)

Comfort Care

CARE IF IN IRREVERSIBLE CONDITION

A irreversible condition means a condition, injury, or illness that may be treated but is never cured or eliminated; that leaves a person unable to care for or make decisions for the person's own self; and that is fatal without life-sustaining treatment provided in accordance with the prevailing standard of medical care.

Life support does not include medical treatment performed in a pre-hospital situation or artificially administered food/water or pain relief.

Comfort care is treatment with the sole objective of relieving pain. It may lengthen or shorten a person's life and does not include artificially administered food and water.

Health Care: Do you want all forms of medical care if your physician considers your condition irreversible, and that you will pass away without life-sustaining treatment? This includes life support, tube feeding, and comfort care(pain relief).

Yes

if No selected above, select which types of care you wish to receive

Life Support

Tube Feeding(food and water)

Comfort Care

Your information

Anyone over 18 years old with a sound mind can create a Living Will.

Health Care, Additional Details Will Creation:

Full Name:
Address:
City/Town:
State:
ZIP Code:

Your Health Care Agent

Anyone over the age of majority and of sound mind can act as your health care agent. Spouses and close family members are common choices.

Health Care: If you are unable to care for yourself, who do you want to make health care decisions for you?

Full Name:
Address:
City/Town:
State:
ZIP Code:
Phone:
Relationship:

(e.g. brother, wife, friend, etc.)

Health Care: Do you want your health care agent to be able to see your medical records?

Yes

Alternate Health Care Agent

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Health Care: Would you like to name an alternative health care agent in case your health care agent is unavailable?

Yes

Only if Yes is chosen above, Provide Alternative Agent's Information

Full Name:
Address:
City/Town:
State:
ZIP Code:
Phone:
Relationship:

(e.g. brother, wife, friend, etc.)

Special Instructions

Including special instructions is completely optional, but if you have any unique circumstances or preferences you may want to mention them. For example, if your religious beliefs prohibit blood transfusions.

Any instructions that don't directly deal with your health care treatment while you are alive should be avoided. After you complete this document, we will show you the appropriate forms for handling any additional estate/financial planning.

A. Each instruction starts with the phrase "I direct that".

B. Write clearly and in full sentences to avoid ambiguity.

C. Do not abbreviate words.

D. Try to limit one instruction to each paragraph.

Health Care: Do you have any special instructions you wish to include?

Yes

If Yes, Complete the following Statement: e.g. I direct that I shall not receive blood transfusions on the basis of my religious beliefs.

Signing Details

Your Living Will must be signed in the same state that you reside in. To change your resident state visit the "Location" step in the progress bar above.

When will this document be signed?

Unsure

Specify Date Below

Document Signature Date:

Which city/town will you sign your Living Will in? *