Temporary Travel Living Will
Date:
Full Name:
Date of Birth:
Country of Passport:
Travel Details
Destination(s):
Trip Dates:
Contact while Traveling:
Medical Care Instructions
If I am unable to make decisions for myself while traveling, I direct the following regarding my medical care:
Emergency Contact
Name:
Relationship:
Phone Number:
Email:
Temporary Healthcare Proxy
Proxy Name:
Relationship:
Phone Number:
Email:
Authority granted during travel period (details):
Additional Instructions
Signature
Date