Advance Health Directive

An Advance Health Directive is a legal document that outlines your medical preferences and appoints someone you trust to make healthcare decisions on your behalf if you become unable to communicate. It ensures your wishes are known and respected during critical health situations, giving peace of mind to you and your loved ones.

Primary Principal's Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of the person you are appointing your Healthcare Agent

First Name

Last Name

Relationship

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Healthcare Agent (If the primary is unwilling or unable to serve)

First Name

Last Name

Relationship

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tertiary Healthcare Agent (If the primary and secondary are unwilling or unable to serve)

First Name

Last Name

Relationship

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country