Military Deployment Medical Power of Attorney

Principal Information

Full Name: Rank/Grade: Branch of Service: Date of Birth: Address:

Agent (Attorney-in-Fact) Information

Full Name: Relationship: Address: Phone Number:

Grant of Authority

I hereby appoint the above-named Agent as my Attorney-in-Fact to consent to, refuse, or withdraw medical treatment on my behalf and to make any and all health care decisions for me if I am unable to do so, effective during my military deployment.

Special Instructions or Limitations

Effective Dates

Start Date: End Date:

Signature

Principal's Signature: Date:

Witness/Notary

Witness Name: Witness Signature: Notary Name: Notary Signature/Seal: Date: