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Medical Power of Attorney - MD Anderson Cancer Center

PATIENT:MDA MRN:LOCATION:PRINT DATE:DOB:SEX: FC: Medical Power of AttorneyDisclosure StatementTHIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make ANY and ALL health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself . Because health care means any treatment, service or procedure to maintain, diagnose, or treat your physical or mental condition, your agent has the Power to make a broad range of health care decisions for you . Your agent may consent, refuse to consent, or withdraw consent to Medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment . Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion.

This Medical Power of Attorney takes effect if I become unable to make my own health care decisions, and this fact is certified in writing by my physician . LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:

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