LDAs are not lawyers and do not offer legal advice, discuss legal strategies, answer questions of a legal nature, select forms for the consumer, or appear in court on the consumer’s behalf.

Advance Health Care Directive Questionnaire

About you

Your first name *

Use your full legal name, as it appears on your ID.

Your middle name

Your last name *

Address

Home street address *

State *

City *

ZIP code *

Your gender

Male

Female

Used for he/she wording in your documents.

County you live in *

Email *

Cell phone *

Home phone (optional)

Your health care agent

Your health care agent: Name, relationship to you, phone, and address *

Your agent is the person who makes health care decisions for you if you can't make them yourself.

First backup agent (optional): Name, relationship to you, phone, and address

Steps in if your agent can't or won't serve.

Second backup agent (optional): Name, relationship to you, phone, and address

When should your agent be able to start making health care decisions for you? *

Only if my doctor decides I can't make my own decisions

Right away, even while I can still decide for myself

The California form starts your agent's authority only when your doctor decides you can't decide for yourself, unless you choose right away.

If a court ever needs to appoint someone to look after you (a conservator), should it be your agent?

Yes

End-of-life choices

Which statement matches your wishes about life support at the end of life? *

Do not prolong my life if I have an incurable condition that will soon cause my death, if I am unconscious and not expected to wake up, or if the burdens of treatment would outweigh the benefits

Prolong my life as long as possible within accepted medical standards

I don't want to choose. My agent will decide

These two choices are copied from the California form. Choose the one that matches your wishes, or leave it to your agent.

Pain relief *

Always give me pain relief and comfort care, even if it may hasten my death

I have exceptions (I'll describe them)

The California form says comfort care and pain relief are always given, even if they may hasten death, unless you list exceptions.

Describe your exceptions for pain relief

Organ and tissue donation

Do you want to donate organs, tissues, or parts after your death? *

Yes, any that are needed

Yes, only the ones I list

Which organs, tissues, or parts?

Example: kidneys, corneas

Donations may be used for (check all that apply)

Transplant

Therapy

Research

Education

Leave all unchecked to allow any of these.

Your doctor

Your primary doctor (optional): name, phone, and address

You can also list a backup doctor.

Medical records access

Should we also prepare a medical records release (HIPAA authorization) so your agents can talk to your doctors and see your records? *

Yes

After death

Wishes for your remains and service (optional)

Burial or cremation, type of service, where, and where your cemetery plot is if you have one.

Anything else

Other health care wishes or instructions (optional)

Anything else you want your agent and doctors to know, such as religious beliefs or treatments you do or don't want.

Upload any relevant documents (optional)

PDF, JPEG, JPG, PNG, DOCX or DOC ( max 10 Files )Any existing advance health care directive or related documents.

Acknowledgement and Authorization

I understand that the Legal Document Assistant (LDA) preparing my documents is NOT an attorney, cannot select forms and DOES NOT give legal advice. I hereby direct the Legal Document Assistant to type and perform certain services as outlined in the Contract for Services which we each executed regarding this matter. I further declare that the foregoing information which I have provided is, to the best of my knowledge, true and correct.

I have read and agree to the acknowledgment above. *

I agree

Your signature *

Clear

Sign

I understand LDAs are not lawyers and do not offer legal advice, discuss legal strategies, answer questions of a legal nature, select forms for the consumer, or appear in court on the consumer's behalf.

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