POWER OF ATTORNEY – HEALTH CARE

    INTAKE FORM








    1. Who would you like to designate as your health care agent?

    First Alternative





    Second Alternative





    Third Alternative





    2. Life sustaining treatment ("LST"): (Choose As Many As Apply)

    (number of physicians) to be terminal and my death is imminent, then LST should be removed.
    number of days) then, remove LST.

    3. Nutrition and hydration: (Choose as many as apply)

    number of days) N&H should be discontinued if not necessary for comfort or alleviation of pain.

    4. Pain Relief: (Chack if applicable)

    5. Power and authority to inspect and disclose information relating to my physical or mental health?

    6. Power to sign documents, waivers and releases?

    7. Authority to authorize autopsy, anatomical gifts and disposition of remains?


    8. Nomination of conservator of person (intended only as a back-up to POA):

    First Alternative





    Second Alternative





    Third Alternative