HEALTH CARE POWER OF ATTORNEY LAYOUT
I. PRINCIPAL’S INFORMATION
I, [Your Name], born on June 15, 1980, residing at [Your Company Address], hereby designate the individual named below as my agent to make medical decisions on my behalf if I am unable to make them myself.
II. AGENT’S INFORMATION
I appoint the following person as my agent:
Name: Sarah Johnson
Address: 123 Maple Street, Springfield, IL 62704
Phone Number: (555) 123-4567
Email: sarah.johnson@example.com
In the event that my agent is unable or unwilling to act on my behalf, I designate the following person as an alternate agent:
Name: Michael Johnson
Address: 456 Oak Avenue, Springfield, IL 62704
Phone Number: (555) 765-4321
Email: michael.johnson@example.com
III. POWERS GRANTED
My agent shall have the authority to make any and all medical decisions on my behalf, including but not limited to:
Decisions regarding medical treatments, procedures, and surgeries.
Decisions concerning the selection of health care providers and facilities.
Decisions regarding the provision of medication and other forms of care.
Decisions about the continuation or withdrawal of life-sustaining treatments.
IV. LIMITATIONS ON AUTHORITY
My agent is not authorized to consent to any experimental treatments and should consult with my family before making decisions regarding end-of-life care.
V. SIGNATURES AND DATE
This document is executed on August 20, 2050.
Printed Name: [Your Name]
Printed Name: Sarah Johnson
VI. WITNESSES OR NOTARIZATION
This document was signed in the presence of the following witnesses:
Name: Emily Carter
Address: 789 Pine Lane, Springfield, IL 62704
Date: August 20, 2050
Name: John Carter
Address: 101 Birch Drive, Springfield, IL 62704
Date: August 20, 2050
Notarization (if applicable):
State of Illinois
Subscribed and sworn before me on August 20, 2050.
Printed Name of Notary Public: Lisa Green
My Commission Expires: March 15, 2055
Power of Attorney Templates @ Template.net
