Digital Advance Directive Form for Dementia Patients
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Healthcare Agent
Name of Healthcare Agent
Relationship to Patient
Agent Phone Number
Agent Email
Advance Directives
Treatment Preferences
Life Support
Resuscitation
Pain Management
Feeding Tube
Other Treatment Preferences
Care Goals
Additional Instructions
Special Wishes or Instructions
Religious or Cultural Preferences
Signatures
Patient's Signature
Date
Witness Name
Witness Signature
Date