Power of Attorney Questionnaire

Complete your Power of Attorney Questionnaire Online

Full Name *:

Email Address *:

Address *:

County *:

Telephone Number *:


Healthcare Matters

Designation of Primary Agent

Note: This individual will make all heath-care decisions for you.

Agent's Full Name:

Agent's Address:

Agent's County:

Agent's Telephone Number:


Agent's Relationship to You:

Designation of Alternate Primary Agent

Agent's Full Name:

Agent's Address:

Agent's County:

Agent's Telephone Number:


Agent's Relationship to You:

Mark the choice that applies to you

If you choose not to prolong life, and you are diagnosed with a terminal illness with no hope of
recovery, please mark which options apply:

Cardiac Resuscitation

Mechanical Respiration (Artificial Breathing)

Tube Feeding

Antibotics

Pain Relief

Maintained in a Vegetative Condition

Additional Wishes:

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