Nevada Medical Power of Attorney
This Nevada Medical Power of Attorney document is designed to comply with the Nevada Revised Statutes. It allows you to appoint a trusted person to make healthcare decisions on your behalf if you become unable to do so.
Please provide the following information accurately to ensure this document meets your needs and is recognized under Nevada law.
Principal's Information
Full Name: ________________________________________
Address: __________________________________________
City, State, Zip: ____________________________________
Date of Birth: ______________________________________
Agent's Information
Full Name of Agent: __________________________________
Relationship to Principal: ____________________________
Primary Phone: ______________________________________
Alternate Phone: ____________________________________
Email Address: ______________________________________
Alternate Agent's Information (Optional)
Full Name of Alternate Agent: _________________________
Relationship to Principal: ____________________________
Primary Phone: ______________________________________
Alternate Phone: ____________________________________
Email Address: ______________________________________
The above-named individual is hereby authorized to make healthcare decisions on my behalf, including but not limited to the power to give, withhold, or withdraw consent to medical treatment, to access medical records, and to make decisions about organ donation, autopsy, and disposition of my body. This authority is subject to any limitations or special instructions I have provided below.
Limitations or Special Instructions:
________________________________________________________________
________________________________________________________________
By signing below, I acknowledge that I have read and understood the terms of this Nevada Medical Power of Attorney and attest to my desire to grant the agent the powers described herein.
Principal's Signature: ___________________________ Date: ________________
This document must be signed in the presence of two witnesses or a notary public, neither of whom is the agent or alternate agent.
Witness 1 Signature: ___________________________ Date: ________________
Print Name: ____________________________________
Relationship to Principal (if any): ________________
Witness 2 Signature: ___________________________ Date: ________________
Print Name: ____________________________________
Relationship to Principal (if any): ________________
OR
Notary Public
State of Nevada )
County of _______________ )
On this __ day of ____________, 20__, before me, a Notary Public, personally appeared _________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained.
In witness whereof, I hereunto set my hand and official seal.
Notary Public Signature: ___________________________
My Commission Expires: ____________________________