(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:
Name of individual you choose as agent: ____________________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: ______________________________
OPTIONAL: If I revoke my agent’s authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:
Name of individual you choose as alternate agent: ____________________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: ______________________________
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:
Name of individual you choose as second alternate agent: ______________________
Address: _____________________________________________________________
City, State, Zip Code: ___________________________________________________
Phone Home _____________________ Work: _______________________________
(1.2) AGENT’S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
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