Medical Power of Attorney (Healthcare Proxy)

Your full name*

Your address*

Person authorized to make medical decisions*

Relationship to you*

Any specific instructions or limits

Date of execution*

Format:

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MEDICAL POWER OF ATTORNEY I, [principal_name], residing at [principal_address], being of sound mind, do hereby authorize [proxy_name], my [proxy_relationship], to make medical decisions on my behalf should I become unable to communicate my own wishes. SPECIFIC INSTRUCTIONS [specific_instructions] This authorization is made in accordance with the framework for advance medical directives recognized by the Supreme Court of India in Common Cause v. Union of India, and is intended to work alongside any separate Living Will I may have executed. [principal_name] Date: [execution_date] WITNESS 1 WITNESS 2 Name: Name: Address: Address:

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Medical Power of Attorney (Healthcare Proxy)

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