Durable Power of ATTORNEY FOR HEALTH CARE & ADVANCE CARE DIRECTIVE/ LIVING WILL.

QUESTIONNAIRE ORDER FORM
( Please print, complete, and mail with payment of $30.00 to Deni PO Box 511 Sunland, Ca 91041)
Document designed for use in all 50 states!

A. This order form is to represent the wishes of: ( FORM CAN BE USED FOR ONE PERSON ONLY )

NAME ___________________________________________________________

ADDRESS_______________________________________________________

CITY_______________________

STATE________

ZIP_______

PHONE # ______________________________

B. First named agent to make health care decisions, on my behalf, & handle future funeral arrangements for me even after my death is:

NAME ___________________________________________________________

ADDRESS_______________________________________________________

CITY______________________ STATE________ ZIP_______

PHONE # ______________________________

C. Second named agent to make health care decisions on my behalf, even after my death is :

NAME ___________________________________________________________

ADDRESS_______________________________________________________

CITY_______________________STATE________ZIP_______

PHONE # ______________________________

My four page advanced health care directive is to include the following requests:

(Please Check off your wishes regarding these subjects)

* It is my specific intent that in the event I have been diagnosed by my treating physicians as having a terminal illness or condition, in which there is no chance of recovery, that my life:

___ (D-I) BE OR ____ (D-2) NOT BE Prolonged by artificial means or aggressive medical therapy.

* It is my specific direction that you shall:

___ ( D-3) NOT OR ____ (D-4) ALWAYS consent to blood transfusions whenever needed, and may consider other alternatives to the same if needed.

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