POWER OF ATTORNEY - HEALTH CARE INTAKE FORM

Law Offices of Cheryl L. Walsh, APC
27282 Calle Arroyo, Suite 200

San Juan Capistrano, CA 92675

Tel: (949) 240-9003; Fax: (949) 240-9083

E-mail: Cheryl@WalshSeniorLaw.com
POWER OF ATTORNEY - HEALTH CARE INTAKE FORM
Full Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
1. Who would you like to designate as your health care agent?
First Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Second Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Third Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
2. Life sustaining treatment ("LST"): (CHOOSE AS MANY AS APPLY)

I desire that my life be prolonged to the greatest possible extent with regards for my physical and mental condition.If I have incurable injury, disease or illness certified by____(number of physicians) to be terminal and my death is imminent, then LST should be removed.If I am in a coma for at least____(number of days) then, remove LST.Withhold LST if burden outweighs benefits.Withhold LST if extension of life would result in mere biological existence.
3. Nutrition and hydration: (CHOOSE AS MANY AS APPLY)

Regardless of condition, it is my desire to receive N&H.If I remain in a coma for ___ (number of days) N&H should be discontinued if not necessary for comfort or alleviation of pain.
4. Pain Relief: (CHECK IF APPLICABLE)

It is my desire that my agent should consent to arrange for an administration of any type of pain relief regardless of whether it leads to permanent damage, addiction or hasten death.
5. Power and authority to inspect and disclose information relating to my physical or mental health?

YesNo
6. Power to sign documents, waivers and releases?

YesNo
7. Authority to authorize autopsy, anatomical gifts and disposition of remains?

YesNo
I want my remains disposed of as follows: (Instructions)
8. Nomination of conservator of person (intended only as a back-up to POA):
First Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Second Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Third Alternative:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Today's Date

MonthDayYear
Should be Empty:

Law Offices of Cheryl L. Walsh, APC

27282 Calle Arroyo, Suite 200

San Juan Capistrano, CA 92675

Tel: (949) 240-9003; Fax: (949) 240-9083

E-mail: Cheryl@WalshSeniorLaw.com

POWER OF ATTORNEY - HEALTH CARE INTAKE FORM