Advance Directive for Patients with Disabilities
Personal Information
Name
Date of Birth
Phone
Address
Disability Information
Primary Disability/Condition
Additional Needs or Accommodations
Preferences Regarding Treatment
Treatment Preferences & Instructions
Assistive Devices and Communication Preferences
Healthcare Proxy/Representative
Name
Relationship
Phone
Other Instructions or Special Considerations
Signatures
Patient/Principal Signature
Date
Witness Signature
Date