Draft Your Healthcare Proxy

Name*

First Last

Address*

Street Address City

State*

Email*

Name of person you want name as your Healthcare Agent*

First Last

This person will be able to make healthcare decisions for you subject to any limitations you list below.

Address*

Street Address City

State*

Phone

Do you want to name as alternate Agent if you first Healthcare Agent is unable or unwilling to serve.*

Alternate Healthcare Agent

First Last

If the first person you name as your Healthcare Agent cannot serve, your second choice for Healthcare Agent.

Address

Street Address Address Line 2 City ZIP Code

State

phone

Limitations*

Please state any decision you do not authorize your healthcare agent to make. If none, enter None.

Healthcare Proxy

Price:

Coupon

Terms and Conditions*

I agree with the terms and conditions for DisabilityResourcesforFamilies.org a product of Disability Resources for Families, Inc.

Total

$0.00