Religious-Specific Advance Directive Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Religion / Faith Tradition
Health Care Proxy / Agent
Name of Health Care Proxy / Agent
Relationship to You
Contact Information
Religious/Spiritual Beliefs Affecting Medical Care
Please specify any religious or spiritual beliefs that should guide your health care decisions:
Religious practices, rituals, or restrictions you wish to be observed:
Clergy or Spiritual Leader to be contacted (Name & Contact Information):
Medical Treatments
Life-sustaining Treatments (artificial ventilation, feeding tubes, resuscitation, etc.):
Treatments or procedures expressly permitted or prohibited by your religion or you personally:
Other Wishes or Instructions Related to Religious Observance and Medical Care:
Signatures
Signature
Date
Witness Signature
Witness Signature