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DURABLE POWER OF ATTORNEY

FOR HEALTH CARE

1. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE:

By this document I, ,________________________________ of

_________________________, intend to create a durable power of attorney for health care

under Division 4.7, Sections 4670-4743 inclusive, of the California Probate Code. This power of

attorney shall not be affected by my subsequent incapacity.

2. DESIGNATION OF HEALTH CARE AGENT:

I do hereby designate and appoint __________________________________________,

as my attorney in fact (referred to in this document as my "agent") to make health care decisions

for me as authorized in this document. For the purposes of this document, "health care decision"

means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or

procedure to maintain, diagnose, or treat my physical or mental condition. If for any reason,

_________________________, is unable or unwilling to serve as my attorney in fact, then I do

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hereby designate and appoint __________________________________________, as my

attorney in fact to make health care decisions for me as authorized in this document. If for any

reason, ________________ is unable or unwilling to serve as my attorney in fact, then I do

hereby designate and appoint _____________________________________, as my attorney in

fact to make health care decisions for me as authorized in this document. If for any reason,

________________________, is unable or unwilling to serve as my attorney in fact, then I do

hereby designate and appoint _____________________________________, as my attorney in

fact to make health care decisions for me as authorized in this document.

3. GENERAL STATEMENT OF AUTHORITY GRANTED:

Subject to any limitations in this document, I hereby grant to my agent full power and

authority to make health care decisions for me to the same extent that I could make such

decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall

make health care decisions that are consistent with my desires as stated in this document, or (if

not inconsistent with my desires as stated in this document) otherwise made known to my agent,

including, but not limited to, my desires concerning obtaining, refusing, or withdrawing life-

prolonging care, treatment, services, and procedures.

4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS:

In exercising the authority under this durable power of attorney for health care, my agent

shall act consistently with my desires as stated below and is subject to the special provisions and

limitations stated below.

(a) STATEMENT OF DESIRES CONCERNING LIFE-PROLONGING

TREATMENT, SERVICES, AND PROCEDURES:

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I do not want to receive medical treatment that, although sustaining my life, has the effect

of prolonging my inevitable death if the burdens of such treatment outweigh the anticipated

benefits. In making this decision, my agent shall consider the quality and duration of my

remaining life if such treatment is provided or continued and the relief from pain if such

treatment is withheld or withdrawn. At the same time that I am signing this durable power of

attorney for health care, I am entering my initials in the space immediately below this provision

to show that I have read this provision and that it reflects my desires.

_______________

BE SURE TO MODIFY THE ABOVE SECTION TO REFLECT YOUR REAL

WISHES, DO NOT JUST USE THE WORDING LISTED HERE.

If I should have an incurable injury, disease, or illness certified by TWO licensed

physicians to be a terminal condition, and if the application of life-sustaining procedures would

serve only to artificially prolong the moment of my death, and if my treating physician

determines that my death is imminent, whether or not life-sustaining procedures are utilized, then

I desire that all life-sustaining treatment be withheld or removed.

BE SURE TO MODIFY THE ABOVE SECTION TO REFLECT YOUR REAL

WISHES, DO NOT JUST USE THE WORDING LISTED HERE.

(b) ADDITIONAL STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND

LIMITATIONS:

I do not wish to be resuscitated if my quality of life is so impaired that I would be

miserable or a tremendous burden to my family. I would only want to live if recovery to a

reasonable quality of life would be possible. Decisions concerning life-support are to be made in

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consensus with any doctors or other health-care professionals.

BE SURE TO MODIFY THE ABOVE SECTION TO REFLECT YOUR REAL

WISHES, DO NOT JUST USE THE WORDING LISTED HERE.

5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY

PHYSICAL OR MENTAL HEALTH:

Subject to any limitations in this document, my agent has the power and authority to do

all of the following:

(a) Request, review, and receive any information, verbal or written, regarding my

physical or mental health, including, but not limited to, medical and hospital records;

(b) Execute on my behalf any releases or other documents that may be required in

order to obtain this information; and

(c) Consent to the disclosure of this information.

6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES:

When necessary to implement the health care decisions that my agent is authorized by

this document to make, my agent has the power and authority to execute on my behalf all of the

following:

(a) Documents titled or purporting to be a "Refusal to Permit Treatment" and

"Leaving Hospital Against Medical Advice" and;

(b) Any necessary waiver or release from liability required by a hospital or physician.

7. ANATOMICAL GIFTS:

My agent shall have the power and authority to make a disposition of any of my parts or

organs under the Uniform Anatomical Gift Act or any similar law with the restriction that any

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disposition of any of my parts or organs shall be for transplant purposes only, and not for any

scientific experimentation at all.

BE SURE TO MODIFY THE ABOVE SECTION TO REFLECT YOUR REAL

WISHES, DO NOT JUST USE THE WORDING LISTED HERE.

8. DISPOSITION OF REMAINS:

My agent shall have the power and authority to direct the disposition of my remains

according to his discretion.

BE SURE TO MODIFY THE ABOVE SECTION TO REFLECT YOUR REAL

WISHES, DO NOT JUST USE THE WORDING LISTED HERE.

9. AUTHORIZATION OF AUTOPSY:

My agent shall have the power and authority to authorize an autopsy.

10. NOMINATION OF CONSERVATOR OF PERSON:

If a conservator of the person is to be appointed for me, I nominate

_________________. If ______________is unable or unwilling to serve as a conservator of the

person then I nominate ________________________. If _______________________________

is unable or unwilling to serve as a conservator of the person then I nominate _______________.

If ______________is unable or unwilling to serve as a conservator of the person then I nominate

________________________.

///

///

///

///

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11. PRIOR DESIGNATIONS REVOKED:

I revoke any prior durable power of attorney for health care.

DATE AND SIGNATURE OF PRINCIPAL

I sign my name to this Durable Power of Attorney for Health Care on _______________,

__________________, at _________________________,California.

____________________________________
NAME OF PERSON SIGNING FORM

A notary public or other officer completing this certificate verifies
only the identity of the person signing the document to which this
__ __
certificate is attached, and not the truthfulness, accuracy, or
validity of that document.

NOTARY ACKNOWLEDGMENT

State of CALIFORNIA

County of ______________.

On _____________ before me, _______________________________________, a notary
public of the State of California, personally appeared __________________________, who
proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to
the within instrument and acknowledged to me that he executed the same in his authorized
capacity, and that by his signature on the instrument the person, or the entity upon behalf of
which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature _______________________________

My commission expires __________________.

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