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Georgia Durable Medical Power of Attorney Form |
The Georgia durable medical power of attorney is
How to Write
Principal
Enter principal`s details.
- Name.
- Date of birth.
Part One: Health Care Agent
Enter agent and alternative agents details.
- Name.
- Address.
- Home telephone number.
- Work telephone number.
- Cell telephone number.
- Email address.
5) Power Of Health Care Agent After Death
A) Autopsy
Decide on agents authority over autopsy.
- Initial to refuse agent authority.
B) Organ Donation And Donation Of Body
Decide on agents actions and authority regarding tissue, organ and body part donation.
- Initial to refuse donation for medical study.
- Initial to refuse donation of organs.
C) Final Disposition Of Body
Enter personal details regarding their wishes over authority of disposition of body
- Principals initials.
- Agent`s name.
- Agent`s address.
- Agent`s home telephone number.
- Agent`s work telephone number.
- Agent`s cell telephone number.
- Agent`s email address.
- Principals initials for preference of either `Buried` or `Cremated`.
Part Two: Treatment Preferences For Health Care Providers
6) Conditions
Decide the types of condition under which the principal would receive treatment.
- A terminal condition.
- A permanent state of unconsciousness.
7) Treatment Preferences
Decide treatment methods.
- (A) Initial to extend life for as long as possible.
- (B) Initial to allow natural death to occur.
- (C)) To refuse medication, mechanical support, assistance via other procedures.
If (c) was initialed then decide which procedures would apply to section (c) above.
- Initial to receive nutrition by means other than directly by mouth.
- Initial to receive fluids by medical means.
- Initial to be assisted with breathing.
- Initial to receive cardiopulmonary resuscitation.
Additional Statement (Optional)
Any of the principal`s other wishes regarding their treatment and medical health.
- Enter details to explain specific course of treatment or medical procedures required.
In Case Of Pregnancy
Understanding of authority in case of pregnancy.
- Initial to show understanding that this document provides no authority should the principal be found to be pregnant.
Part 3: Guardianship (Optional)
Decide on an appointed guardian.
- (A) Initial to appoint the health care professional in Part 1 as the guardian.
- (B) Initial to nominate a person to be the guardian.
If initialed (B) to nominate a person, enter their personal details.
- Name.
- Address.
- Home telephone number.
- Work telephone number.
- Cell telephone number.
- Email address.
Part Four: Effectiveness And Signatures
Signify effectiveness of the health care directive.
- Principal`s initials.
- (Optional) Date of commencement of health care directive.
- (Optional) Date health care directive ceases.
Principals Consent
Enter principals details for consent to document.
- Principal`s signature.
- Date.
Witnesses
Enter witnesses details.
- Signature.
- Printed name.
- Address.
- Date.
