MEDICAL POWER OF ATTORNEY
This Deed of Power of Attorney is executed on this at .
BE IT KNOWN THAT
, S/oD/o
, resident of
(hereinafter referred to as the
"Principal"
which expression shall, unless it be repugnant to the context or meaning thereof, means and includes its heirs, executors, administrators, legal representatives/ the partners or partner for the time being of the firm the survivors or survivor of them and the heirs, executors, administrators of the last surviving partner and his or her assigns/ its successors and assigns ) of the
ONE PART
do hereby appoint, nominate and constitute
, S/oD/o , resident of (hereinafter referred to as the "Attorney" which expression shall, unless it be repugnant to the context or meaning thereof, means and includes its heirs, executors, administrators, legal representatives/ the partners or partner for the time being of the firm the survivors or survivor of them and the heirs, executors, administrators of the last surviving partner and his or her assigns/ its successors and assigns ) of the OTHER PART
WHEREAS, hereinafter each shall be referred to as “Principal” and collectively as the “Principals” . Wherever the context permits, it shall collectively be referred to as “Parties” and individually as “Party” .
NOW KNOW ALL AND THOSE PRESENT WITNESS THAT
I, the PRINCIPAL of the ONE PART, do hereby appoint, nominate and constitute , S/oD/o and residing at
As our true and lawful attorney to execute and/or do all or any of the acts or things or as my true and lawful attorney in my name and on my behalf to do or execute and/or cause to be done all or any of the acts or things or deed hereinafter mentioned in respect to my health condition, namely:
1. To make and communicate my healthcare decisions when I cannot do so, in the event that I lack the capacity to provide informed consent or refusal of medical treatment.
2. To provide my attorney the power to consent to, refuse, or stop any healthcare, treatment, service, or procedure, except to the extent to limit those decisions in this document.
3. To authorize my attorney to communicate with healthcare personnel, get information, and sign forms as necessary to carry out those decisions.
4. In the event that my attorney resigns, dies or is otherwise unable or unwilling to so act, then I appoint the following person(s) to serve in order below:
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Attorney name:
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Alternative Attorney:
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6. The attorney is authorized to direct that artificially provided fluids and nutrition, such as feeding tube or intravenous infusion, be withheld or withdrawn.
7. The attorney is authorized to make all medical decisions on my behalf, except for the following:
8.
*** ******** ** ********** ** *******, ******, *** ******* *** ***********, ****** ** *******, ********* ** ******** ** ****** ******, *********, *** *** ******* **, ******* *** ******** *******, *** ** ******* ** *** ********** ** **** ***********.
9.
Employing or discharging my health care providers.
10. Consenting to and authorizing my admission to and discharge from a hospital, nursing or convalescent home, hospice, long-term care facility, or other health care facility.
11.
********** ** *** *********** ** ********* ** *** ********* ** * ******** *** *** **** ** ********* ** ****** *******.
12.
Consenting to and authorizing the administration of medications for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as “shock treatment.”
13.
Giving consent for, withdrawing consent for, or withholding consent for, X-ray, anaesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist, podiatrist, or other health care provider. This authorization specifically includes the power to consent to measures for the relief of pain.
14. To provide my medical information at the request of any individual acting as my attorney-in-fact under a power of attorney or as a Trustee or successor Trustee, or at the request of any other individual whom my health care attorney believes should have such information. I desire that such information be provided whenever it would expedite the prompt and proper handling of my affairs or the affairs of any person or entity for which I have some responsibility. In addition, I authorize my healthcare attorney to take any and all legal steps necessary to ensure compliance with my instructions providing access to my protected health information. Such steps shall include resorting to any and all legal procedures in and out of courts as may be necessary to enforce my rights under the law and shall include attempting to recover attorneys’ fees against anyone who does not comply with this health care power of attorney.
15. Taking any lawful actions that may be necessary to carry out these decisions, including but not limited to: (i) signing, executing, delivering, and acknowledging any agreement, release, authorization, or other documents that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of these powers; (ii) granting releases of liability to medical providers or others; and (iii) incurring reasonable costs on my behalf related to exercising these powers, provided that this health care power of attorney shall not give my health care agent general authority over my property or financial affairs.
16. This Health Care Power of Attorney is intended to be valid in any jurisdiction in which it is presented. The powers delegated under this power of attorney are severable so that the invalidity of one or more powers shall not affect any others.
17.
This power of attorney shall not be affected or revoked by my incapacity or mental incompetence.
18. My health care attorney and my health care agent's estate, heirs, successors, and assigns are hereby released and forever discharged by me, my estate, my heirs, successors, assigns and personal representatives from all liability and from all claims or demands of all kinds arising out of my health care agent's acts or omissions, except for my health care agent’s willful misconduct or gross negligence.
19. No act or omission of my health care attorney, or of any other person, entity, institution, or facility acting in good faith in reliance on the authority of my health care agent pursuant to this Health Care Power of Attorney shall be considered suicide, nor the cause of my
death for any civil or criminal purposes, nor shall it be considered unprofessional conduct or a lack of professional competence. Any person, entity, institution, or facility against whom criminal or civil liability is asserted because of conduct authorized by this Health Care Power of Attorney may interpose this document as a defence.
20. My healthcare attorney shall be entitled to reimbursement for all reasonable expenses incurred as a result of carrying out any provision of this directive.
21. To do, execute and perform all acts, and things whatsoever which in the opinion of my said Attorney ought to be done, executed and performed in relation to the power hereinabove conferred concerning my health.
GENERALLY to do all such act/s, deed/s, matter/s or thing/s whatsoever my said Attorney, under the power in that health hereinbefore contained, shall lawfully do, execute or perform in the exercise of the power, authorities and liberties hereby conferred upon, under and by virtue of this Deed.
FURTHER GENERALLY to do all such acts, deeds, matters and things as may be necessary as my Attorney shall think fit and proper, notwithstanding no express power or authority in that behalf is hereinabove provided.
AND WE DO HEREBY AGREE that all acts, deeds and things lawfully done by my said Attorney or attorneys shall be construed as acts, deeds and things done by me and I undertake to ratify and confirm all and whatsoever that my said Attorney shall lawfully do or cause to be done for me by virtue of the power/s herein above given. provided that all such actions relate exclusively to the property and its management thereof;
IN WITNESS WHEREOF , this Power of Attorney has been executed on the day, month and year as mentioned earlier hereinabove in the presence of the following witnesses
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Signed, Sealed and Delivered by Principal |
Signature |
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Signed, Sealed and Delivered by Attorney |
Signature |
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In presence of the witnesses ... ... ...
Witness 1:
Witness 2: