I appoint _____________________________ (NAME) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and communicate an informed decision regarding treatment, my health care agent is authorized to:

(1) Convey to my physician my wishes concerning the withholding or removal of life support systems.

(2) Take whatever actions are necessary to ensure that my :wishes are given effect.

If this person is unwilling or unable to serve as my health care agent, I appoint __________________ (NAME) to be my alternative health care agent.

This request is made, after careful reflection, while I am of sound mind.

Date _______________, 200____                                               x_____________________________

This document was signed in our presence, by the above-named _____________________________ (NAME) who appeared to be eighteen years of age or older, or sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed.

x____________________________                                           x_____________________________
(Witness)                                                                                      (Witness)

x____________________________                                           x_____________________________
(Number and Street)                                                                     (Number and Street)

x____________________________                                           x_____________________________
(City, State and Zip Code)                                                           (City, State and Zip)