Advance Directive for Military Veterans
Personal Information
Full Name
Date of Birth
Military Service Number/ID
Branch of Service
Rank
Health Care Agent Information
Name of Health Care Agent
Relationship
Phone Number
Address
Directive Instructions
Care Preferences and Medical Treatment Wishes
Life Support / Life-Sustaining Treatment Instructions
Military-Related Considerations
Military-Related Concerns or Benefits
VA Claims and Benefits Contacts
Other Instructions
Funeral, Burial, or Memorial Preferences
Other Wishes or Comments
Signatures
Veteran's Signature
Date
Witness 1 Signature
Date
Witness 2 Signature
Date