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Virginia Living Will and Medical Power of Attorney (Advance Directive) |
The Virginia advance medical directive is a combination of a living will and a medical power of attorney. By using this document the principal can have the choice of what treatment they will receive when they can no longer make the choices themselves through serious illness such as a coma or permanent unconsciousness. If the principal wishes they can make specific instructions or they can appoint a person to instruct on their behalf. The principal may also state a particular date where the document becomes effective and / or ineffective. The Virginia advanced health care directive requires 2 witnesses, it is a formal declaration and is legally binding in the state of Virginia becoming invalid should the patient be found to be pregnant. It is created in accordance to the US statutes §§54.1-2981 to 54.1-2993.
How to Write
Durable Power Of Attorney For Health Care And Living Will
The principal must initial, date and enter the last four digits of their social security number on every page.
Personal Details
The principal must enter their details.
- Name.
- Address.
- ZIP code.
- Last four digits of social security number.
- Home/Work/Mobile telephone numbers.
Health Care Agent
The principal must choose to appoint a health care agent and alternative agent or choose not to.
- Initial to decline the selection of an agent.
- Initial to select an agent.
- Agent`s name.
- Agent`s address.
- Agent`s ZIP code.
- Relationship status of agent to principal.
- Home/Work/Mobile telephone numbers.
Preferences Regarding Life Sustaining Treatments
The principal must initial the relevant box according to their preferences of life sustaining treatment. `Yes`, `Not Sure/Depends` or `No`.
- Unconscious, in a coma or a vegetative state with little chance of recovery.
- Permanent severe brain damage.
- Permanent condition requiring assistance with daily tasks.
- On a breathing machine.
- In pain or with severe symptoms.
- Imminent death.
Mental Health Preferences (Optional)
The principal may enter any details they feel relevant to their mental health care.
Additional Preferences (Optional)
The principal may enter details of any other medical health care preferences they may have.
Degree To Which Preferences Must Be Followed
The principal must show how they want their wishes to be carried out by initialing the relevant statement.
- To use wishes as a guide only.
- To use wishes as an explicit instruction.
Signatures
The principal, witnesses and notary must enter their details.
- Principal`s signature.
- Date.
- Witnesses signatures.
- Date.
- Witnesses name.
- Witnesses address.
- Witnesses ZIP code.
- Date.
- Principal`s name.
- County.
- State.
- Notary`s signature.
- Date of expiration of commission.
