Example 1

Here is an example of a personal directive that names specific health care decisions and also names an Agent and an alternate agent.

     I, Joe Sample, willfully and voluntarily make this declaration as a directive to be followed if I become unable to participate in decisions regarding my medical care.

With respect to any life-sustaining treatment, I direct the following:

          Preserve my life as long as possible.

With respect to any other health care and personal decisions I direct the following:

Jane Sample to be my agent

And in the event Jane Sample is unable to fulfill the duties of agent, I direct the following:

Steve Sleeve to be my alternate agent.

Joe Sample

Joe Sample

December 5th, 2017

I declare I am eligible to be an Agent, and accept the instructions in the directive and duties of an agent in the Act.

The Director and Agents voluntarily signed this document in my presence.

Example 2

Here is an example of a personal directive that names an Agent, and does not name specific health care decisions.

     I, Jane Suzie, willfully and voluntarily make this declaration as a directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my medical care.

With respect to any personal decision, I direct the following:

          Jane Sample to be my agent.

Jane Suzie

Jane Suzie

December 5th, 2017

I declare I am eligible to be an Agent, and accept the instructions in the directive and the duties of an agent in the Act.

Jane Sample

Jane Sample

December 5th, 2017

The Director and Agent voluntarily signed this document in my presence.

Example 3

Here is an example of a personal directive that names specific health care decisions, and does not name an agent.

     I, Shirley Louise willfully and voluntarily make this declaration as a directive to be followed if I become unable to participate in decisions regarding my medical care.

With respect to any life-sustaining treatment, I direct the following:

I direct that no life-sustaining treatment be provided. If life-sustaining treatment is begun, terminate it.

Shirley Louise

Shirley Louise

December 15th, 2017

The Director voluntarily signed this document in my presence.