Who is this for? This person is known as the "Patient" Residing in the county of County Where the Patient lives Health Care Agent Who will be the Agent that can make MEDICAL DECISIONS for the Patient? The Agent can make medical decisions for the Patient ONLY IF the Patient cannot make the decisions for themselves. Health Care Agent's Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Relationship to the Principal Relationship to the Principal SpouseFamily MemberFriendOther Enter Relationship: Health Care Agent's Telephone Health Care Agent's E-Mail 2nd Agent If the Health Care Agent is not available, do you want to appoint a 2nd Health Care Agent? If the Health Care Agent is not available, do you want to appoint a 2nd Health Care Agent? YesNo The 2nd Health Care Agent would not have the power to act UNLESS the original Health Care Agent is not available. 2nd Agent's Name 2nd Agent's Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Relationship to the Principal Relationship to the Principal SpouseFamily Member FriendOther Enter the Relationship: 2nd Agent's Phone Number 2nd Agent's E-Mail 3rd Agent Do you want to select a 3rd Health Care Agent? Do you want to select a 3rd Health Care Agent? YesNo 3rd Health Care Agent's Name 3rd Agent's Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Relationship to the Principal Relationship to the Principal SpouseFamily Member FriendOther Enter the Relationship: 3rd Agent's Phone Number 3rd Agent's E-Mail Priorities What are the Principal's priorities for medical care? (check all that apply) What are the Principal's priorities for medical care? (check all that apply) ComfortPain ReliefProlong Life as Long as PossibleOther Enter the Additional Requests: Powers to End Life If the Principal should be in a terminal condition, will the Health Care Agent have the power of end their life? If the Principal should be in a terminal condition, will the Health Care Agent have the power of end their life? YesNo Enter the Principal's Initials Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Enter the Principal's Initials Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Drugs Do you request that drugs be given to the Principal to provide comfort? Do you request that drugs be given to the Principal to provide comfort? YesNo This is even if the drugs could be considered to have addictive properties. Withdrawal of Life-Support Does the Principal direct that all life-prolonging procedures be WITHDRAWN if there are no curable options? Does the Principal direct that all life-prolonging procedures be WITHDRAWN if there are no curable options? YesNo In the event of brain damage or the Principal is in a terminal stage. CPR Authorization Do you authorize Heart-Lung Resuscitation (CPR) if you cannot speak for yourself? Do you authorize Heart-Lung Resuscitation (CPR) if you cannot speak for yourself? YesNo Mechanical Ventilator Authorization Do you authorize a Mechanical Ventilator (breathing machine) if you cannot speak for yourself? Do you authorize a Mechanical Ventilator (breathing machine) if you cannot speak for yourself? YesNo Dialysis Authorization Do you authorize a Dialysis (kidney machine) if you cannot speak for yourself? Do you authorize a Dialysis (kidney machine) if you cannot speak for yourself? YesNo Surgery Authorization Do you authorize Surgery if you cannot speak for yourself? Do you authorize Surgery if you cannot speak for yourself? YesNo Chemotherapy Authorization Do you authorize Chemotherapy if you cannot speak for yourself? Do you authorize Chemotherapy if you cannot speak for yourself? YesNo Radiation Treatment Authorization Do you authorize Radiation Treatment if you cannot speak for yourself? Do you authorize Radiation Treatment if you cannot speak for yourself? YesNo Antibiotics Authorization Do you authorize Antibiotics if you cannot speak for yourself? Do you authorize Antibiotics if you cannot speak for yourself? YesNo Feeding and Breathing If the Principal is in a Terminal Condition, do they request Feeding and Breathing tubes? If the Principal is in a Terminal Condition, do they request Feeding and Breathing tubes? YesNo Enter the Principal's Initials Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Enter the Principal's Initials Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Directions to Agent This Form should be followed by the Agent as: (choose one) This Form should be followed by the Agent as: (choose one) Strict instructions when when making medical decisions for the Principal.Guidance when making medical decisions for the Principal. Enter the Principal's Initials Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Will there be any exceptions? Will there be any exceptions? YesNo Enter any Exceptions: Enter the Principal's Initials to Confirm Clear Please draw your initials. If the Principal is not available, click "Next" and they can enter at a later time. Organ Donation Does the Principal wish to donate their organs after death? Does the Principal wish to donate their organs after death? YesYes with conditionsNo Enter the Principal's Initials Clear Please draw your initials. Enter the Principal's Initials Clear Please draw your initials. Enter any limitations: Signing Requirements Under Pennsylvania law, this Form must be signed with Two (2) Witnesses Under Pennsylvania law, this Form must be signed with Two (2) Witnesses I Agree It is preferable, although not required, that the witnesses are not your heirs, creditors, nor employed by any of your health care providers. Signing Date Do you know the DATE this Form will be signed? Do you know the DATE this Form will be signed? YesNo Enter the Signing Date Notarization Are you going to have this Form be Notarized? Are you going to have this Form be Notarized? YesNo Notarizing is not required under Pennsylvania law. Although, it would allow this Form to be accepted in another State. Next Save Save and finish later