Medical Power of Attorney
I hereby appoint:
Agent Name:
Agent Address:
Agent Phone:
as my attorney-in-fact to make healthcare decisions for me as authorized in this document.
Powers Granted
The Agent may exercise the following powers concerning my medical care and treatment:
- Consent to or refuse medical treatment
- Access medical records
- Make decisions concerning life-sustaining treatment
- Other related health care decisions
Special Instructions (if any):
Signatures
Principal Signature:
Date:
Printed Name of Witness:
Notary Public (if required):
My commission expires: