Georgia Durable Medical Power of Attorney Form

The Georgia durable medical power of attorney is

How to Write


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.



Enter witnesses details.

  • Signature.
  • Printed name.
  • Address.
  • Date.