Advance Health Care Directive

Please fill out the following form for your health care directive

Summary and Questionnaire

Step 1 of 3

The following is a brief summary of the Georgia Advance Health Care Directive. Included are the pertinent questions you need to ask yourself to determine your health care preferences should you not be able to communicate them to your doctors and family members. It is so important to have an Advance Health Care Directive in place before the unthinkable happens like a serious accident or sudden debilitating illness. The State of Georgia on July 1, 2007 to simplify the process and encourage more Georgians to execute an Advance Health Care Directive combined the Living Will (sometimes referred to as a DNR) with the durable power of attorney also called the Health Care Agency appointment. Georgia also included the option to nominate a guardian which would be approved by the court if the court deems guardianship necessary. I would be honored to help you and your spouse execute an Advance Health Care Directive. Please answer the questions below on the next few pages and return to me. I will produce the documents for you to sign and give to your loved ones and health care providers. Spence Hoard Financial Counselor First Baptist Woodstock 678.494.2697

Name(Required)

First Middle Last

Gender(Required)

Your Email Address(Required)

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Health Care Agency

You may appoint an agent to make decisions and act on your behalf concerning any type of health care when you are unable to communicate your wishes. This person should be someone close to you like a relative or very close friend who you usually communicate with on a regular basis. Your health care agent should be someone who lives close enough to be reasonably accessible in case you are incapacitated due to illness or accident. This appointment may be revoked at any time by choosing a new agent and executing a new Health Care Agency document.

First Heath Care Agent

First Health Care Agent Name(Required)

First Last

First Health Care Agent Address(Required)

Street Address Address Line 2 City State ZIP Code

First Health Care Agent Email(Required)

First Health Care Agent Phone(Required)

Do you have a back up health care agent?(Required)

Back Up Heath Care Agent

Who do you wish to appoint as your back up health care agent?(Required)

First Last

Back Up Health Care Agent Address(Required)

Street Address Address Line 2 City State ZIP Code

Back Up Health Care Agent Email(Required)

Back Up Health Care Agent Phone(Required)

Do you have a second back up health care agent that you would like to list?(Required)

Second Back Up Heath Care Agent

Second Back Up Health Care Agent Name(Required)

First Last

Second Back Up Health Care Agent Address(Required)

Street Address Address Line 2 City State ZIP Code

Second Back Up Health Care Agent Email(Required)

Second Back Up Health Care Agent Phone(Required)

Treatment Preferences and Final Disposition of Your body

Do you wish for your health care agent to be empowered to authorize an autopsy?(Required)

Do you wish for your health care agent to have power to make a disposition of your body for use in medical research?(Required)

Do you wish for your health care agent to have power to donate any of your organs?(Required)

Do you wish to give someone other than your health care agent the power to make final disposition of your body?(Required)

If yes, who is that person?

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

I wish for my preferences in Part Two to be effective if I am in any of the following conditions:

I have terminal condition which is incurable or irreversible that will result in my death in a relatively short period of time or if I am in a permanent unconscious state which means I am in an incurable or irreversible condition in which I am not aware of myself or my environment and show no behavioral response to my environment.(Required)

In regards to pain, I direct that treatment for alleviation of pain or discomfort be provided at all times even if it hastens my death.(Required)

Your wishes for treatment

Your wishes for treatment(Required)

If I am in any condition that I chose above and I can no longer communicate my treatment preferences after efforts have been made to communicate with me, then select A, B or C below.(choose only one).

(A) Try to extend my life for as long as possible, using any and all medication and machines or procedures that could keep me alive. If I am unable to take nutrition or fluids by mouth, then I wish to receive them by tubes.
OR
(B) Allow my natural death to occur. I do not want any medicines, machines, or other medical procedures that could keep me alive but cannot cure me. I do not want to receive nutrition or fluids by tube or other medical means except as needed for pain medication.
OR
(C) I do not want any medicines or machines or other procedures that could keep me alive but cannot cure me except as follows:

If I am unable to take nutrition by mouth, I want nutrition by tube.(Required)

If I am unable to take fluids by mouth, I want fluids by tube.(Required)

If I need assistance to breathe, I want a ventilator.(Required)

If my heart or pulse stops, I want to have CPR used.(Required)

Do you have any other specific wishes regarding pain relief that are not covered in previous sections?(Required)

In case of pregnancy, I want part two of the Georgia Advance Directive to be carried out if my fetus is not viable.(Required)

(Georgia law does not permit Part Two to be carried out if the fetus is viable.)

Questions?

If you have any questions, please contact us for further information.

Advance Health Care Directive

Please fill out the following form for your health care directive

Health Care Agency

First Heath Care Agent

Back Up Heath Care Agent

Second Back Up Heath Care Agent

Treatment Preferences and Final Disposition of Your body

Your wishes for treatment

Questions?

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