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 INFORMATION
YOUR Name
Your answer
YOUR Address
Your answer
YOUR Telephone Number
Your answer
YOUR E-Mail Address
Your answer
YOUR Date of Birth
Your answer
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