Transcription of Advance Care Directive DIY Kit
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Advance Care Directive DIY Kit
Advance Care Directive Form By completing this Advance Care Directive you can choose to: 1. Appoint one or more Substitute Decision-Makers and/or 2. W. rite down your values and wishes to guide decisions about your future health care, end of life, living arrangements and other personal matters and/or 3. W. rite down health care you do not want in particular circumstances. Part 1 Part 1: Personal details You must fill in Name:_____. this Part. (Full name of person giving Advance Care Directive ). Address:_____. Ph:_____ Date of birth:_____/_____/_____. Part 2a Only fill in Part 2a if you want to appoint one or more Substitute Decision-Makers. Your Substitute Part 2a: Appointing Substitute Decision-Makers Decision- Maker fills in I appoint:_____.
page 2 of the Guide. b) Ocomut es of care you wish to avoid For more information and suggested statements see page 3 of the Guide. c) Health care you prefer For more information and suggested statements see page 4 of the Guide. Part 3 continued on next page Please draw a large “Z” across any blank sections.
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