Durable Power of Attorney for Health Care - Nevada

DPA.HC (1-02) -3- Principal______
with respect to health care decisions, I hereby grant to the
attorney-in-fact named above full power and authority to make health
care decisions for me before, or after my death, including:
consent, refusal of consent, or withdrawal of consent to any care,
treatment,
service, or procedure to maintain, diagnose, or treat a physical or
mental condition, subject only to the limitations and special
provision, if any, set forth in paragraph 4 or 6.
4. SPECIAL PROVISIONS AND LIMITATIONS.
(Your attorney-in-fact is not permitted to consent to any of
the following: commitment to or placement in a mental health
treatment facility, convulsive treatment, psycho surgery,
sterilization, or abortion. If there are any other types of
treatment or placement that you do not want your attorney-in-fact's
authority to give consent for or other restrictions you wish to
place on his or her attorney-in-fact's authority, you should list
them in the space below. If you do not write any limitations, your
attorney-in-fact will have the broad powers to make health care
decisions on your behalf which are set forth in paragraph 3, except
to the extent that there are limits provided by law.)
In exercising the authority under this durable power of
attorney for health care, the authority of my attorney-in-fact is
subject to the following special provisions and limitations:
____________________________________________________________________
_
____________________________________________________________________
_
5. DURATION.
I understand that this power of attorney will exist
indefinitely from the date I execute this document unless I
establish a shorter time. If I am unable to make health care
decisions for myself when this power of attorney expires, the
authority I have granted my attorney-in-fact will continue to exist
until the time when I become able to make health care decisions for
myself.
(IF APPLICABLE)
I wish to have this power of attorney end on the following
date: _________________________________.
6. STATEMENT OF DESIRES.
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