THIS MEDICAL POWER OF ATTORNEY is made this 25 December 2024 by PARTY_1_NAME (Identification Number: DONOR_ID), of PARTY_1_ADDRESS_SINGLE_LINE. 

I hereby revoke any previous power of attorney for medical/personal care and appoint PARTY_2_NAME (Identification Number: ATT_ID), of PARTY_2_ADDRESS_SINGLE_LINE (the "Attorney") as my true and lawful attorney on my behalf and in his / her name or otherwise to do all acts and things and to execute and sign all deeds and documents which he/she considers necessary or advisable in connection with my medical, health and care decisions, including but not limited to:

☐  giving or refusing consent to health care (excluding life-sustaining treatment);

☐  giving or refusing consent to life-sustaining treatment on my behalf;

☐  staying in my own home and getting help and support from social services;

☐  moving into residential care and finding a good care home;

☐  day-to-day matters such as my diet, dress or daily routine;

☐  who to live with and whether to refuse access to specific individuals;

☐  legal matters relating to personal care, including whether to consent to a forensic examination;

☐  everyday decisions as to health care or other decisions of a similar nature.

This Power is valid upon execution. The Attorney shall act with my consent when I still have mental capacity. I intend this power of attorney to continue even if I become mentally incapable. 

 

This Power is governed by and shall be construed in accordance with the laws of JURISDICTION_STATE.

 

In witness whereof, I have hereunto set my hand and seal.

SIGNED, SEALED and DELIVERED	)
by	)
in the presence of:	)
[specify the name(s) of the 2 directors / witnesses]	)

Name, address and signature of witnesses -

Signature:

Name:

Address:

Signature:

Name:

Address:

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