POWER OF ATTORNEY - HEALTH CARE INTAKE FORM

Law Offices of Cheryl L. Walsh

31431 Rancho Viejo Rd., Ste. 102

San Juan Capistrano, CA 92675

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

E-mail: Cheryl@WalshSeniorLaw.com

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1. Who would you like to designate as your health care agent?

First Alternative:

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Second Alternative:

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Third Alternative:

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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?

Yes No

6. Power to sign documents, waivers and releases?

Yes No

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

Yes No

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:

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First Name Last Name

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Second Alternative:

Full Name

First Name Last Name

Address

Street Address
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Postal / Zip Code	Country

Phone Number

Area Code Phone Number

Third Alternative:

Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

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