Health Care Proxy Information Form
Please follow the prompts to fill out all pertinent questions to the best of your ability.

If you wish to have a Proxy prepared for a couple who both have the same wishes and wish to designate each other as their Health Care Agent, there will be a box to check towards the end of the form. Simply fill out the form with information for one of the individuals and I will prepare both forms, switching the names as appropriate. (If you have different wishes or desire different Agents, please each fill in a separate form)

There will be a space for any additional explanation or questions at the end.

Please Be Sure to Click "SUBMIT" At the End of the Form!!!!
YOUR Name *
YOUR Address *
YOUR Telephone Number *
YOUR E-Mail Address *
YOUR Date of Birth *
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