Durable Power of Attorney for Health Care
1. Principal Information
Full Name
Address
2. Designation of Health Care Agent
Agent's Full Name
Agent's Address
Agent's Phone
3. Alternate Agent (Optional)
Alternate Agent's Full Name
Alternate Agent's Address
Alternate Agent's Phone
4. Instructions to Health Care Agent
Special Instructions
5. Signature and Date
Principal's Signature
Date
6. Witnesses
Witness 1 Name
Witness 1 Signature
Witness 2 Name
Witness 2 Signature
Date