Advanced Healthcare Directive

1
Your Name* This field is required.
First Name
Middle Name
Last Name
2
Your Contact Information* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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3
Your Primary Phone Number* This field is required.
Area Code
Phone Number
4
Your Email Address* This field is required.
5
How did you hear about us?
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6
Check Each Kind of Power of Attorney You Would Like
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ORDER SUMMARY
Total costUSD
Durable Power of Attorney (Financial Decisions)Preparation of Durable Power of Attorney Document
$150.00Edit
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Advanced Healthcare DirectivePreparation of Advanced Healthcare Directive
$150.00Edit
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First Name
Last Name
7
List the name of the person you wish to appoint as your agent for financial decisions* This field is required.Your financial agent will be able to take care of financial decisions for you in the event you cannot due so.
8
Do you wish to list an alternate financial agent if your original agent cannot serve?* This field is required.Your alternate will be able to act under the power of attorney if your initial agent is not able to or declines to act.
Yes
No
9
List the name(s) of any alternate financial agents* This field is required.Type the number by each set in succession (i.e. 1. John Doe; 2. Jane Doe) Each alternate set shall come after the other in sequential order. You may also choose more than one person as co-agents (i.e. 1. John Doe, Jane Doe. 2....)
10
List the name of the person you wish to appoint as your agent for healthcare decisions* This field is required.Your healthcare agent will be in charge of your healthcare decisions in the event you become incapacitated.
11
Do you wish to list an alternate healthcare agent if your original agent cannot serve?* This field is required.
Yes
No
12
List the name(s) of any alternate healthcare agents* This field is required.Type the number by each set in succession (i.e. 1. John Doe; 2. Jane Doe) Each alternate set shall come after the other in sequential order. You may also choose more than one person as co-agents (i.e. 1. John Doe, Jane Doe. 2....)
13
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