Pediatric Advance Directive Form
Patient Information
Child's Name
Date of Birth
Medical Record Number
Parent/Guardian Name
Relationship to Child
Advance Directive Preferences
Goals of Care
Medical Interventions to Use or Avoid
Comfort Measures/Quality of Life Preferences
Spiritual or Cultural Preferences
Decision Makers
Primary Medical Decision Maker
Alternate Decision Maker (if any)
Signatures
Parent/Guardian Signature
Date
Clinician Signature
Date