LIVING WILL & HEALTHCARE PROXY

LIVING WILL & HEALTHCARE PROXY
Basic information
1. Today's Date

Month Day Year
Date
2. Name

First Name Last Name
3. Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
4. Date

Month Day Year
Date
5. Place of Birth
6. Phone Number
Please enter a valid phone number.
7. Email
example@example.com
8. If Married, please complete this section.
8A. Name of Spouse

First Name Last Name
8B. Spouse's Date of Birth

Month Day Year
Date
8C. Spouse's place of birth.
Example: Springfield, PA , USA.
8D. Spouse's Last Known Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
9. **Next of Kin
Relationship to you:
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
10. Do you want a Healthcare proxy?

Yes No
A healthcare proxy is someone you trust to make healthcare decisions on your behalf if you are not able to communicate your wishes.

Note: If you choose NOT to have a healthcare proxy, you can select no and leave this section blank.

*If you are married and do not appoint anyone as a healthcare proxy, then your spouse has rights to decide medical treatment for you.

**If you are NOT married, and do not appoint anyone as a healthcare proxy, your next of kin may have right to decide medical treatment for you.

If "YES" Please complete the following for healthcare procy. A second healthcare proxy may be listed as a backup in case the first one cannot do it.
10A. First Healthcare Proxy
Full Legal Name

First Name Last Name
Date of birth

Month Day Year
Date
Place of birth
Phone Number
Please enter a valid phone number.
10B. Second Healthcare Proxy (backup)
Full Legal Name

First Name Last Name
Date of birth

Month Day Year
Date
Place of birth
Phone Number
Please enter a valid phone number.

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