By signing below, I confirm:
- I understand this care directive documents my preferences to guide my healthcare team.
- In providing appropriate care for me when I am unable to speak for myself
- I understand treatments that would not benefit me will not be provided even if I have specifically asked for them.
- I agree that this care directive can be in electronic format and will be made available to all healthcare providers who are, or will be, caring for me.
Name
Signature Date
HEALTHCARE PROFESSIONAL STATEMENT
By signing below the healthcare professional confirms that:
- I believe the principal was competent at the time the advanced care directive was filled out.
- I have discussed the health and the care choices available to the principle.
- I am satisfied that the principal made this advance care directive with adequate information; and
- I am satisfied that the principal has made the choices in their advance care directive voluntarily and without coercion.
Healthcare Practitioner
Name: _________________________________________________
Designation ____________________
Facility/organisation: ______________________________________
Phone: ___________
Signature____________________________
Date_______________
Witness
I confirm that__________________signed this document on………/……. /………..
Signed: _________________________Name: ____________________
Address: ________________________________Phone: _____________