Health Care Proxy

HEALTH CARE PROXY
I       appoint Agent       having an address at       as my agent to make all health care
decisions for me, except to the extent I express otherwise.
This health care proxy shall take effect, if and when I am unable to make my own health care
decisions.
NOTE: I hereby instruct my agent as follows:      
NOTE: I hereby limit my agent’s authority as follows:      
NOTE:      
I direct that my agent to make any and all health care decisions according to my instructions as
stated above or as otherwise made known to him or her. I also direct my agent to conform to any
limitations on his or her authority as stated above or as otherwise made known to him or her.
In the event the person I appoint above is unable, unwilling or unavailable to act as my health
care agent, I hereby appoint       having an address at      .
It is understood that, unless I revoke it, this proxy will remain in effect indefinitely or until the
date or occurrence of any condition I state below:
This proxy shall expire on      
Signature Date
     
Address
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