End of Life Directive (Display Prominently)

End of Life Directive (Display Prominently)

Instructions: This form should be completed with your physician and displayed prominently in the home (typically attached to the refrigerator or in an emergency medical kit).
I, First Name* Last Name* , do not want any resuscitative measures for (insert patient's name) First Name* Last Name*(insert "myself", or name of child if for a child less than 16)
PATIENT INFORMATION:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Manitoba Health Number:*
PATIENT'S SIGNATURE: (if the patient is a child less than 16 years old, a parent or the legal guardian of the patient should sign; if the patient is otherwise not legally competent, the legal guardian or health care proxy should sign on the patient's behalf)*

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(printed name, if signed by patient's parent, guardian or proxy)*

First NameLast Name
WITNESS' SIGNATURE:*

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Witness's Printed Name: (witness must be 18 years of age or older)*

First NameLast Name
Date of Patient's and Witness' Signature (MM/DD/YYY):*

MonthDayYear
Date
Name of Attending Physician:*

First NameLast Name
Physician's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Physician's Signature (optional):

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Date of Physician's Signature (MM/DD/YYY):

MonthDayYear
Date
Email of Respondent (emailed pdf of form will be sent to this address)*
example@example.com
Should be Empty: