Springing Medical Power of Attorney
Principal Information
Full Name
Address
Phone
Agent Information
Agent Full Name
Agent Address
Agent Phone
Alternate Agent Information (Optional)
Alternate Agent Name
Alternate Agent Address
Alternate Agent Phone
Triggering Condition
This power of attorney becomes effective upon certification by (Specify conditions and/or physicians required):
Medical Powers Granted
Details or limitations on agent’s authority:
Expiration (if any)
Expiration Date or Event
Principal Signature
Date
Witness #1 Name
Witness #1 Signature
Witness #2 Name
Witness #2 Signature
Notary Public (if required):