COVID-19 Specific Advance Directive
Personal Information
Full Name
Date of Birth
Address
Healthcare Agent
Name
Contact Information
Relationship to You
COVID-19 Treatment Preferences
Ventilator Use
Hospitalization/ICU Admission
Experimental Treatments
Additional Instructions
Other Specific Wishes (e.g. palliative care, visitation, etc.)
Signatures
Signature of Person Completing Directive
Date
Signature of Witness
Date