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born alive. I also direct that lifesaving procedures be used even 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
(b) Additional statement of desires, special provisions, and limitations regarding health
See above instructions.
(You may attached additional pages if you need more space to complete your statement. If you
attach additional pages, you must date and sign EACH of the additional pages at the same time
you date and sign this document.) If you wish to make a gift of any bodily organ you may do so
pursuant to the Uniform Anatomical Gift Act.
(c) Statement of desire regarding organ and tissue donation:
Initial if applicable:
[ ] In the event of my death, I request that my agent inform my family/next of kin of my
desire to be an organ and tissue donor, if possible. (You may attach additional pages if you need
more space to complete your statement. If you attach additional pages, you must date and sign
EACH of the additional pages at the same time you date and sign this document.
5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY
PHYSICAL OR MENTAL HEALTH
Subject to any limitations in this document, my agent has the power and authority to do all of the
(a) Request, review, and receive any information, verbal or written, regarding my
physical or mental health, including by not limited to, medical and hospital records.
(b) Execute on my behalf any releases or other documents that may be required in
order to obtain this information.
(c) Consent to the disclosure of this information.