Medical Power of Attorney Form - Texas

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT
I have been provided with a Disclosure Statement explaining the effect of this document.
I have read and understood that information contained in the Disclosure Statement.
PRINCIPAL SIGNATURE
(You must date and sign this power of attorney)
I sign my name to this medical power of attorney on _____________ day of
___________, 20______, at ________________________________________
(City and State)
____________________________________ _____________________________
(Signature) (Print Name)
____________________________________________ ______________________
(Address) (Date of Birth)
STATEMENT OF FIRST WITNESS
I am not the person appointed as agent by this document. I am not related to the principal
by blood or marriage. I would not be entitled to any portion of the principals estate on
the principals death. I am not the attending physician of the principal or an employee of
the attending physician. I have no claim against any portion of the principals estate on
the principals death. Furthermore, if I am an employee of a healthcare facility in which
the principal is a patient, I am not involved in providing direct patient care to the
principal and am not an officer, director, partner, or business office employee of the
healthcare facility or of any parent organization of the healthcare facility.
Signature: ____________________________________________________________
Print Name: __________________________________ Date: ___________________
Address: _____________________________________________________________
SIGNATURE OF SECOND WITNESS
Signature: ____________________________________________________________
Print Name: __________________________________ Date: ___________________
Address: _____________________________________________________________
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Medical Power of Attorney Form - Texas PDF

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