Vermont Durable Medical Power of Attorney Form

The Vermont durable medical power of attorney needs two witnesses to make it recognizable by law in the state of Vermont and optionally a notary and is in accordance with the US statutes §9700 – 9720. The document is designed to legally give power to a patient to appoint another person to make decisions regarding their healthcare should they be too ill to do this for them self,  for example if suffering from severe brain damage and mental impairment or nearing the end of their life.

How to Write

Power Of Attorney For Health Care

The principal`s and agent`s details must be entered.

  • Name of principal.
  • Name of agent.
  • Address of agent.


Wishes And Limitations

The principal must enter details of any specific wishes or limitations they wish to have regarding their medical health care.


Alternative Agent

The details of an alternative agent may be entered.

  • Agent`s name.
  • Agent`s address.



  • The  location where the original version of this document will be kept must be entered.
  • The details of any persons (including names and addresses) who will posses a copy of this document must be entered.



The principal and witnesses must enter their details.

  • Date.
  • Principals signature.
  • Witnesses signature.
  • Witnesses address.
  • Date.
  • Ombudsman`s Hospital representative`s address.
  • Ombudsman`s Hospital representative`s name.