New York Health Care Proxy
(1) I, _____________________________________________________, hereby appoint:
Agent’s Home Address:
Agent’s Telephone Numbers:
as my health care agent to make any and all health care decisions for me,
except to the extent that I state otherwise.
This proxy shall take effect only when and if I become unable to make my
own health care decisions.
(2) Optional: Alternate
If the person I appoint is unable, unwilling or unavailable to act as my
health care agent, I hereby appoint:
Alternate’s Home Address:
Alternate’s Telephone Numbers:
(3) Unless I revoke it, this proxy shall remain in effect indefinitely or until
the date or condition I have stated below. (Optional: If you want this
proxy to expire, state the date or conditions here.) This proxy will
expire (specify date or conditions):
(4) Optional Instructions: I direct my agent to make health decisions in
accordance with my wishes and limitations as stated below, or as he or
she otherwise knows. (attach additional pages as necessary)
My agent knows my wishes regarding artificial nutrition and hydration.