Section A: Personal Details
Please provide your personal details and contact details so we know how to get in touch with you.
As you are appointing other people to make decisions on your behalf, you are known as 'the donor'.
You must be at least 18 years old and be able to understand and make decisions for yourself (called 'mental capacity').
Title
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Name
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First Name
Last Name
What is your date of birth?
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Day
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Month
Year
Date
Contact email
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Phone
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
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Referral
Newspaper
Online Advert
Word of mouth
Google search
Other
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Health and Welfare LPA
The Attorneys
The people you choose to make decisions for you are called your ‘attorneys’. Your attorneys do not need special legal knowledge or training. They should be people you trust and know well. People usually choose their husband, wife or partner, son or daughter, or best friend.
You need to choose at least one attorney, but you can have more. How many attorneys would you like to appoint?
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Attorney #1
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Attorney #2
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Attorney #3
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Attorney #4
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
How should your attorneys make decisions? You need to choose whether your attorneys can make decisions on their own or must agree some or all decisions unanimously. Click an option below to find out more about it.
I only appointed one attorney
Jointly and severally
Jointly
Jointly for some decisions, jointly and severally for other decisions
Unsure, I would like to discuss further
Jointly and severally
Attorneys can make decisions on their own or together. Most people choose this option because it’s the most practical. Attorneys can gettogether to make important decisions if they wish, but can make simple or urgent decisions on their own. It’s up to the attorneys to choose when they act together or alone. It also means that if one of the attorneys dies or can no longer act, your LPA will still work. If one attorney makes a decision, it has the same effect as if all the attorneys made that decision.
Jointly
Attorneys must agree unanimously on every decision, however big or small. Remember, some simple decisions could be delayed because it takes time to get the attorneys together. If your attorneys can’t agree a decision, then they can only make that decision by going to court. Be careful – if one attorney dies or can no longer act, all your attorneys become unable to act. This is because the law says a group appointed ‘jointly’ is a single unit. Your LPA will stop working unless you appoint at least one replacement attorney.
Jointly for some decisions, jointly and severally for other decisions
Attorneys must agree unanimously on some decisions, but can make others on their own. If you choose this option, you must list the decisions your attorneys should make jointly and agree unanimously in your LPA. The wording you use is important. Be careful – if one of your attorneys dies or can no longer act, none of your attorneys will be able to make any of the decisions you’ve said should be made jointly. Your LPA will stop working for those decisions unless you appoint at least one replacement attorney. Your original attorneys will still be able to make any of the other decisions alongside your replacement attorneys.
Replacement attorneys are a backup in case one of your original attorneys cannot make decisions for you any more. Would you like to appoint any replacement attorneys?
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Please Select
Yes
No
How many replacement attorneys would you like to appoint?
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If you would like to appoint more than 2, please provide these details in Section E.
Replacement Attorney #1
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Replacement Attorney #2
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
Life-sustaining treatment
You must choose whether your attorneys can give or refuse consent to life-sustaining treatment on your behalf. Life-sustaining treatment includes care, surgery, medicine or other help from doctors that is needed to keep you alive, such as a serious operation (including a heart bypass or organ transplant), cancer treatment or artificial nutrition or hydration.
Who do you want to make decisions about life-sustaining treatment?
Please Select
My attorneys
My doctors
I give my attorneys authority
Your attorneys can speak to doctors on your behalf as if they were you. They can give or refuse consent to life-sustaining treatment on your behalf
I do not give my attorneys authority
Your doctors will take into account the views of the attorneys and of people who are interested in your welfare as well as any written statement you may have made, where it is practical and appropriate.
People to notify
You can let people know that you are going to register your LPA. They can raise any concerns that they have about the LPA, such as if there was any pressure or fraud in making it. When the LPA is registered, the person applying (either you or one of your attorneys) must send a notice to each 'person to notify'.
Would you like to notify anyone of your LPA? (This excludes attorneys and replacement attorneys)
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Please Select
Yes
No
How many people would you like to notify?
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If you would like to appoint more than 2, please provide these details in Section E.
Person #1
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person #2
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person #3
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person #4
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferences and instructions
You can tell your attorneys how you would prefer them to make decisions, or give them specific instructions which they must follow when making decisions.
Your attorneys do not have to follow your preferences but they should keep them in mind. Would you like to include any preferences in your LPA?
Please Select
Yes
No
Unsure and would like to discuss further
Please outline your preferences here using words like 'prefer' and 'would like':
Your attorneys must follow your instructions exactly. Would you like to include any instructions in your LPA?
Please Select
Yes
No
Unsure and would like to discuss further
Please outline your instructions here using words like 'must' and 'have to':
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Section E: Final Questions and Next Steps
Please provide details of anything else you think we ought to know:
Please note any additional questions you would like to raise at our meeting:
The next stage will be for us to arrange a chat with you to confirm your instructions and answer any questions you may have. Please select the following platform of your preference:
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Google Meet
Microsoft Teams
Skype
Zoom
Other
Please also select the best time to meet:
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