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Advanced Health Care Directive (Medical Power of Attorney) Order Form Provided by Just Document Preparation: Legal Document
Assistant and Paralegal Services

Your Name

Your Phone Number

Your Contact Email

Principal: Person Giving Medical Power of Attorney (Full Legal Name)

Agent: Person who acts on behalf of principal. (Full Legal Name)

Home phone number:

Alternate phone number:

Alternate Agent (Optional) (Full Legal Name)

Home phone number:

Alternate phone number:

Choices for Life Support:

1. Choice Not To Prolong Life:
I request that all treatments other than those needed to keep me comfortable be discontinued or
withheld and my physician(s) allow me to die as gently as possible.

2. Choice To Prolong Life:
I want my life to be prolonged as long as possible within the limits of generally accepted health
care standards.

Completed Documents email address:

I agree to the Terms and
Conditions of this order:

Please Type "I Agree" to Agree

Once we receive your order we will call to confirm your information and
process your payment over the phone.

ADD A POWER OF
ATTORNEY FOR $25.00.
CLICK HERE TO GO TO THE
ORDER FORM.

Call with any question
while filling out this form.
(951) 685-5444

We are not attorneys. We can only provide self help services at your specific direction.
Riverside LDA #062-San Bernardino LDA#146

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Advanced Health Care Directive (Medical Power of Attorney) Order Form Provided by Just Document Preparation: Legal Document Assistant and Paralegal Services

Advanced Health Care Directive (Medical Power of Attorney) Order Form Provided by Just Document Preparation: Legal Document
Assistant and Paralegal Services