THIS MEDICAL POWER OF ATTORNEY is made this 02 May 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: ATT1_ID), of PARTY_2_ADDRESS_SINGLE_LINE, PARTY_3_NAME, Identification number: ATT2_ID of PARTY_3_ADDRESS_SINGLE_LINE and PARTY_4_NAME (Identification Number: ATT3_ID), of PARTY_4_ADDRESS_SINGLE_LINE (the "Attorneys") as my true and lawful attorneys to act  on my behalf and in their name or otherwise to do all acts and things and to execute and sign all deeds and documents which they consider 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) on my behalf;

☐  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]	)

........................................