Healthcare intake form - Northern Nevada Legal Aid

POWER OF ATTORNEY – HEALTH CARE

INTAKE FORM

Full Name

Age

Date of Birth

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

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

First Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

Second Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

Third Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

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

If I have incurable injury, disease or illness certified by(number of physicians) to be terminal and my death is imminent, then LST should be removed.

If I am in a coma for at leastnumber of days) then, remove LST.

Withhold LST if burden outweighs benefits.

Withhold LST if extension of life would result in mere biological existence.

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

Regardless of condition, it is my desire to receive N&H

If I remain in a coma fornumber of days) N&H should be discontinued if not necessary for comfort or alleviation of pain.

4. Pain Relief: (Chack if applicable)

It is my desire that my agent should consent to arrange for an administration of any type of pain relief regardless of whether it leads to permanent damage, addiction or hasten death.

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

YesNo

6. Power to sign documents, waivers and releases?

YesNo

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

YesNo

I want my remains disposed of as follows

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

First Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

Second Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

Third Alternative

Full Name

Physical Address

Mailing Address (If different than physical)

Email Address

Telephone Number

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)

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

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

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