Create Durable Power of Attorney for Health Care

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Contact Information
Your Name*
First Last
Email*
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Principal Information
Principal's Name*
First Last
Principal's Address*
Street Address Address Line 2 City State ZIP Code

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Primary Agent Information
Primary Agent Name*
First Last
Primary Agent Address*
Street Address Address Line 2 City State ZIP Code
Successor Agent Information
Successor Agent Name*
First Last
Successor Agent Address*
Street Address Address Line 2 City State ZIP Code

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Agent Powers
Agent Powers
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- Access to and control over all medical and personal information.
- To execute waivers, medical authorizations and such other documentation that may be required to permit or authorize my medical care or discontinue care.
- To make decisions that may allow my death.
- To give consent or refusal with respect to any medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or nature, including life sustaining treatments such as artificial nutrition and hydration.
- To hire or discharge any medical personnel.
Additional Instructions
Additional Instructions*

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