Page 71 - Guardian Hospice Care
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l, _____________________________________________________, being of sound mind willfully and voluntarily constitute and appoint,
_________________________________________________________________________________ Or, if unwilling or unable, _________________________________________________________________________________
To be my true, sufficient, and lawful attorney-in-fact for me and in my name to make any and all medical decisions on my behalf, in the event I become incapacitated, including the right to accept or refuse surgical or medical treatment.
My attorney-in-fact is hereby relieved of any liability that may occur as a result of any decision made in connection with this power of attorney.
It is my intention that this power of attorney be in full force and effect until revoked by me or until my death, whichever occurs first.
In witness whereof I hereunto set my hand this ________________________________ day of _______________________________________________________,20 _______________________.
Signature: _______________________________________________________________________ Print Name:____________________________________________MR#:_____________________
Witness: _________________________________________________________________________ Witness: _________________________________________________________________________

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