Durable Power of Attorney for Health Care Will to Live Form - Iowa

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IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and
health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above
special conditions applying if there is a chance that prolonging my life might allow my child to
be born alive. I also direct that lifesaving procedures be used even if I am legally determined to
be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I
specify by writing my signature in the box below, no one is authorized to consent to any
procedure for me that would result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal condition as defined above,
medical procedures required to prevent my death are authorized even if they may result in the
death of my unborn child provided every possible effort is made to preserve both my life and the
life of my unborn child.
____________________________________
Signature of Declarant
I, (print name)_________________________________________________, sign my name to
this Durable Power of Attorney for Health Care on this _____ day of _____________________,
20______.
(Signature)____________________________________________________________________
FIRST ALTERNATIVE: WITNESS STATEMENT
I declare that the person who signed this document is personally known to me, that s/he signed
this durable power of attorney in my presence, and that s/he appears to be of sound mind and
under no duress, fraud or undue influence. I am not the person designated as attorney in fact by
this document, nor am I the principal’s health care provider or an employee of the principal’s
health care provider. I am at least eighteen years of age.
First Witness Signature:__________________________________________________________
Date:_____________________Print Name:__________________________________________
Address:______________________________________________________________________
________________________________________ Phone Number:________________________
Second Witness Signature:________________________________________________________
Date:_____________________Print Name:__________________________________________
Address:______________________________________________________________________
________________________________________ Phone Number:________________________
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Durable Power of Attorney for Health Care Will to Live Form - Iowa PDF

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