Sample Healthcare Proxy Form - Massachusetts

4
If the principal is physically incapable of signing:
I hereby sign the name of the principal at the principal’s
direction and in the presence of the principal and two witnesses.
Name of Principal: _______________________________________
Name of Signatory: _______________________________________
Date: _______________________________________
Address of Signatory: _______________________________________
_______________________________________
WITNESSES:
We, the undersigned, have witnessed the signing of this document by the
principal or at the direction of the principal and state that to the best of our
knowledge, the principal is at least 18 years of age, of sound mind, and
under no constraint or undue influence. We, the witnesses, have not been
named as Healthcare Agents.
1. ______________________________ ___________
Witness (Sign) Date
______________________________
Print Name
____________________________________________________________
Address
2. ______________________________ ___________
Witness (Sign) Date
______________________________
Print Name
____________________________________________________________
Address
Notarization
Commonwealth of Massachusetts
County of _________________
On this ___________ day of _____________, _____, before me, the under-
signed, a notary public of the Commonwealth of Massachusetts, personally
appeared (client name), proved to me through satisfactory evidence of
identification, which was __________________________, personally known
to me or proven on the basis of satisfactory evidence to be the person
whose name is subscribed to this instrument, a Healthcare Proxy, and
acknowledged that he executed it voluntarily and for its stated purpose.
514 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health
Page 4/5
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Sample Healthcare Proxy Form - Massachusetts PDF

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