Advance Directive - English (new)

ADVANCE DIRECTIVE ACKNOWLEDGMENT

ADVANCE DIRECTIVE ACKNOWLEDGMENTFOR ADULT PATIENTS ONLY (18 OR OLDER)
An Advance Health Care Directive (AHCD) lets you have a say about how you want to be treated if you get very sick. Please ask a CMC front desk team member for a copy of the California AHCD packet.

Patient acknowledgement of advance health care directive (AHCD) information received
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I have been informed of my right to formulate an AHCD.
Please initial
I understand that I am not required to have an AHCD in order to receive medical Initial treatment at this health care facility.
Please initial
Please check one

I have an executed AHCDI do not have an executed AHCD
Should be Empty:

ADVANCE DIRECTIVE ACKNOWLEDGMENT