Advance Directive: Religious Preferences
Personal Information
Full Name
Date of Birth
Address
Religious Affiliation
Religion / Faith Tradition
Religious Leader / Contact
Name
Phone
Email
Religious Directives or Practices
Please specify any religious beliefs, directives, or practices that should be considered in your medical care:
End-of-Life Preferences
Specify any end-of-life rituals, restrictions, or practices:
Other Notes
Additional instructions or information:
Signature
Your Name
Date