LDAs are not lawyers and do not offer legal advice, discuss legal strategies, answer questions of a legal nature, select forms for the consumer, or appear in court on the consumer’s behalf.

DURABLE POWER OF ATTORNEY AND HEALTHCARE DIRECTIVE QUESTIONNAIRE

Skip PERSONAL INFORMATION section if you have already completed a Will/Trust Questionnaire

PERSONAL INFORMATION SECTION:

  • YOUR PERSONAL INFORMATION
  • Gender Male Female
  • YOUR SPOUSE’S PERSONAL INFORMATION
  • Gender Male Female
  • DURABLE POWER OF ATTORNEY
  • Effective date of your Power of Attorney only when incapacitated immediately immediately
  • My incapacity shall be determined by: my Agent (Attorney, in Fact). This is someone I can trust to act on my behalf to conduct business, sign documents, talk to the bank or insurance agents, etc. (typically, this is my Spouse first, then an alternate, and then a second alternate. Also, this is typically the same person I name as my alternate successor trustees in my trust and alternate Executors in my will after my Spouse.
  • One doctor chosen by my attorney-in-fact
    One doctor I name:
    Two doctors chosen by my attorney-in-fact
    Two doctors I name:
  • My attorney in fact shall be: 1 person 2 people 3 people Co-Agents
  • Attorney-in-Fact (1)
  • Attorney-in-Fact (2) (check if alternate for 1) Check if co-agent
  • Attorney-in-Fact (2) (check if alternate for 2) Check if co-agent
  • If you are appointing co-agents, please describe how they should serve:
  • Do you require your attorney-in-fact to make periodic reports?
    Yes No
  • If yes, who should the reports be submitted to
  • HEALTHCARE DIRECTIVE
  • If you are diagnosed as having a terminal condition and can no longer direct your medical care: (Check one):
  • I do not want any life-prolonging procedures and
    DO DO NOT want food and water artificially administered
    DO DO NOT want all pain reduction and/or comfort care
    I want some life-prolonging procedures, but not others (check all desired):
    Blood and Blood products CPR Diagnostic tests Dialysis Drugs Respirator Surgery
  • I want all life-prolonging procedures
  • If you are diagnosed as being in a permanent coma and can no longer direct your medical care: (Check one):
  • I do not want any life-prolonging procedures and
    DO DO NOT want food and water artificially administered
    DO DO NOT want all pain reduction and/or comfort care
    I want some life-prolonging procedures, but not others (check all desired):
    Blood and Blood products CPR Diagnostic tests Dialysis Drugs Respirator Surgery
  • I want all life-prolonging procedures
  • I desire the following representative to oversee my wishes: Attorney-in-Fact #1 #2 #3
  • I desire the following representative to act as an alternate: Attorney-in-Fact #1 #2 #3
  • FEMALES ONLY: If I am pregnant when my healthcare directive is considered:
  • I direct it be given no effect during my pregnancy I direct that it be carried out

  • ACKNOWLEDGMENT AND AUTHORIZATION

  • I understand that the Legal Document Assistant (LDA) preparing my documents is NOT an attorney, cannot select forms and DOES NOT give legal advice. I hereby direct the Legal Document Assistant to type and perform certain services as outlined in the Contract for Services which we each executed regarding this matter. I further declare that the foregoing information which I have provided is, to the best of my knowledge, true and correct.

  • Just check on this box below to verify *