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PATIENT NAME I want to make my wishes known in advance in case I become unable to make an
 

Summary: PATIENT NAME
MR#
I want to make my wishes known in advance in case I become unable to make an
informed decision about my medical care. I, _________________________________
willfully and voluntarily make known my desire and do hereby declare:
(Cross through this box and initial if you do not want to appoint an agent to make health-care decisions)
"Durable Medical Power of Attorney for Health Care"Portion of Advance Medical Directive
I hereby appoint the following as my primary agent to make health care decisions for me if I
become incapable of making decisions for myself:
Primary agent name ____________________________ Day phone ______________________
Address _____________________________________Evening phone __________________
If my primary agent is unavailable or is unable or unwilling to make decisions for me, I ap-
point the following person as my substitute agent:
Substitute agent name _________________________ Day phone ______________________
Address ______________________________________Evening phone ___________________
Under Virginia law, the powers of my agent include: (You may cross through and initial any statement)
A. To consent to or refuse or withdraw consent to any type of medical care, treatment, surgical procedure,
diagnostic procedure, medication, and the use of mechanical or other procedures that affect any bodily
function; including, but not limited to artificial respiration (being put on a respirator), artificially adminis-
tered nutrition and hydration using an IV or feeding tube, and cardiopulmonary resuscitation (CPR). This

  

Source: Acton, Scott - Department of Electrical and Computer Engineering, University of Virginia

 

Collections: Computer Technologies and Information Sciences