Advance Care Directive DIY Kit

Advance care Directive Form1 of 6 Advance care Directive FormCertification statement or JP stampYo u r initial:_____ Witness initial:_____ Date:___/___/___See page 15 for suggested certification statementPart 2a (continued over page)Part 1 You must fill in this 2aYour Substitute Decision-Maker fills in this section and must sign before you must provide the Substitute Decision-Maker with the Substitute Decision-Maker Guidelines prior to completing this section. Your Substitute Decision-Maker fills in this section. gIf you did not fill in any of this Part please draw a large Z across the blank 1: Personal detailsName: _____ (Full name of person giving Advance care Directive )Address: _____Ph: _____ Date of birth: ____/ ____/ _____Only fill in Part 2a if you want to appoint one or more Substitute 2a: Appointing Substitute Decision-MakersI appoint: _____(Name of appointed Substitute Decision-Maker)Address: _____Ph: _____ Date of birth: ____/ ____/ _____I, _____(Name of appointed Substitute Decision-Maker)am over 18 years old, and I understand and accept my role and the responsibilities of being a Substitute Decision-Maker as set out in the Substitute Decision-Maker : _____ Date: ____/ ____/ _____ (Signature of appointed Substitute Decision-Maker)By completing this Advance care Directive you can choose to:1.

Advance Care Directive Form 1 of 6 Advance Care Certification statement or P stamp Directive Form Your _____: al i t ni i Witness _____: al i t ni i

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  Care, Directive, Advance, Advance care directive, Advance care directive diy kit, Advance care

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