Advance Directive
Patient Name
First Name
Middle Name
Last Name
Date Reviewed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective Date of Directive
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
Times Discussed:
Documents:
Living Will
Scanned Advance Directive Document on File
Verified by:
Verified with patient and is current
Verified with family only
Verified by medical records only
Name
Prefix
First Name
Last Name
Relationship
Status:
Reviewed
Reviewed, detailed document
Directives on File
None
Refused
Resuscitation:
Attempt resuscitation/CPR
Do not attempt resuscitation/DNR
Place on life support:
No
Yes
Intubation:
No
Yes
Antibiotics:
No
Yes
IV Fluid and Support:
No
Yes
Tube Feeding:
No
Yes
Blood/Blood Products
No
Yes
Other directives:
Durable Power of Attorney OR Healthcare Proxy?
Durable Power of Attorney
Healthcare Proxy
Durable Power of Attorney
Relationship
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Effective Date of Representation:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration of representation: (if indefinitely, please write indefinitely)
Healthcare Proxy
Relationship
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Extension
Effective Date of Representation:
-
Month
-
Day
Year
Date Picker Icon
Duration of Representation: (if indefinitely, please write indefinitely)
Comments
Submit
Should be Empty: