Health Care Directive Questionnaire

Please answer the following questions as thoroughly as possible as to ensure that we accurately describe your wishes in your Health Care Directive. We will prepare the documents based on this information and have them ready to be signed, witnessed, and notarized when you come in to the office. Please note that not all of these questions may apply to you. If they do not, please put N/A in the space provided for that particular question.

NOTE: This form checks for proper format of phone numbers and email addresses. If you have errors in the processing of this form, you will have to re-enter the Verification code, along with the corrected data, before the form will process.

* Required Information
BASIC APPLICANT INFORMATION

Address where the applicant resides:

Mailing address, if different than residential address:

PART ONE: HEALTH CARE AGENT - SECTION 1

Insert N/A if question not applicable to you.

I select the following person as my health care agent to make health care decisions for me:

PART ONE: BACK-UP HEALTH CARE AGENT - SECTION 2

Insert N/A if question not applicable to you.

[This section is optional. PART ONE will be effective even if this section is left blank.]

If my health care agent cannot be contacted in a reasonable time period and cannot be located with reasonable efforts or for any reason my health care agent is unavailable, unable or unwilling to act as my health care agent, then I select the following, each to act successively in the order named, as my back-up health care agent(s):

PART ONE: GENERAL POWERS OF HEALTH CARE AGENT- SECTION 3

Reviewed during appointment time at RGC-Law.

PART ONE: GUIDANCE FOR HEALTH CARE AGENT - SECTION 4

Reviewed during appointment time at RGC-Law.

PART ONE: POWERS OF HEALTH CARE AGENT AFTER DEATH - SECTION 5

AUTOPSY

My health care agent (HCA) will have the power to authorize an autopsy of my body unless I have limited my health care agent's power by noting below.

Yes

No

ORGAN DONATION AND DONATION OF BODY

My health care agent (HCA) will have the power to make a disposition of any part or all of my body for medical purposes pursuant to the Georgia Anatomical Gift Act, unless I have limited my health care agent's power by noting below.

Yes

No

Yes

No

FINAL DISPOSITION OF BODY

My health care agent (HCA) will have the power to make decisions about the final disposition of my body unless noted below.

I want the following person to make decisions about the final disposition of my body (leave blank if HCA has power).

Buried

Cremated

PART TWO: TREATMENT PREFERENCES - SECTION 6

PART TWO will be effective if I am in any of the following conditions:

[Check an appropriate response for each condition in which you want PART TWO to be effective.]

Yes

No

Yes

No

My condition will be determined in writing after personal examination by my attending physician and a second physician in accordance with currently accepted medical standards.

PART TWO: TREATMENT PREFERENCES - SECTION 7

[State you treatment preference by choosing (A), (B) or (C). If you choose (C), state your additional treatment preferences by choosing one or more of the statements following (C). You may provide additional instructions about your treatment preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state your specific preferences regarding pain relief in the next section.]

If I am in any condition that I noted in Section (6) above and I can no longer communicate my treatment preferences after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences, then:

(A) Try to extend my life for as long as possible, using all medications, machines, or other medical procedures that in reasonable medical judgement could keep me alive. If I am unable to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.

(B) Allow my natural death to occur. I do not want any medications, machines, or other medical procedures that in reasonable medical judgement could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed to provide pain medication.

(C) I do not want any medications, machines, or other medical procedures that in reasonable medical judgement could keep me alive but cannot cure me, except as follows:

Select only if you choose C above...

If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.

If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.

If I need assistance to breathe, I want to have a ventilator used.

If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

PART TWO: TREATMENT PREFERENCES - SECTION 8

Add any additionals statements not mentioned in Section (7) above in the box below:

PART TWO: TREATMENT PREFERENCES - SECTION 9

[PART TWO will be effective even if this section is left blank.]

IN CASE OF PREGNANCY

I understand that under Georgia law, PART TWO generally will have no force and effect if I am pregnant unless the fetus is not viable and I indicate by noting below that I want PART TWO to be carried out.

I want PART TWO to be carried out if my fetus is not viable.

PART THREE: GUARDIANSHIP - SECTION 10

[State you preference by choosing (A) or (B). Choose (A) only if you have also completed PART ONE.]

(A) I nominate the person serving as my health care agent under PART ONE to serve as my guardian.

(B) I nominate the following person to serve as my guardian:

PART FOUR: EFFECTIVENESS AND SIGNATURES

This advance directive for health care will become effective only if I am unable or choose not to make or communicate my own health care decisions. This form revokes any advance directive for health care, durable power of attorney for health care, health care proxy, or living will that I have completed before this date. Unless I have noted below and have provided alternative future dates or events, this advance directive for health care will become effective at the time I sign it and will remain effective until my death (and after my death to the extent authorized in Section (5) of PART ONE).

This advance directive for health care will become effective on or upon _________________ and will terminate on or upon ____________. Dates to be filled in at signing in the RGC-Law offices.

Verification and Comments

Verify

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* Required Information

Please read before submitting

Please review this form prior to clicking on the 'Send Questionaire' button for any items that are 'required' yet left blank. Also check for accuracy in the spelling of names.

NOTE: This form checks for proper format of phone numbers and email addresses. If you have errors in the processing of this form, you will have to re-enter the Verification code, along with the corrected data, before the form will process.