I, _______________, certify that I am serving as the attending physician for ____________________ of __________, who has been under my care since the ____ day of __________, ______.
1. This declarant, _______________________________, is currently suffering from the following injury, disease, or illness: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
2. I certify that I have explained to the declarant to the extent he is able to understand, and to the available persons acting as proxy, the reasonable available alternatives for his care and treatment.
3. I certify that the care and treatment alternatives directed below are: ______ (a) directed by the declarant; or ______ (b) that the declarant has a physical or mental condition which renders him unable to give personal directions for care and treatment and that the care and treatment alternatives directed below are in my opinion, and in the opinion of the declarant's proxy, what the declarant would probably decide if able to give current directions concerning his care and treatment.
Date: _______________
Signature of attending physician: __________________________________________
The following care and treatment or withholding of treatment is directed with respect to the declarant: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Signature of declarant or of person authorized by law to sign on declarant's behalf:
_____________________________________________________________
Relationship to declarant: _______________________________
Address of Signer: _______________________________________________________________
(City, County, and State of residence of Signer)
We witnesses certify that each of us is 18 years of age or older; that we personally witnessed the declarant or a proxy sign this directive; that we are acquainted with the declarant and believe that care and treatment alternatives directed above are what the declarant has decided for himself concerning his care and treatment, or, if the foregoing was signed by a proxy, that we are acquainted with the proxy and believe that the proxy sincerely believes that the care and treatment alternatives directed above are what the declarant would probably decide for himself if he were able to give current directions concerning his care and treatment; that neither of us signed the above directive for or on behalf of declarant; that we are not related to the declarant by blood or marriage nor are we entitled to any portion of declarant's estate according to the laws of intestate succession of this state or under any will or codicil of the declarant; that we are not directly financially responsible for declarant's medical care; and that we are not agents of any health care facility in which declarant may be a patient at the time of signing this directive.
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Signature of Witness
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Address of Witness
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Signature of Witness
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Address of Witness