Oklahoma Medical Power of Attorney
This Oklahoma Medical Power of Attorney ("Document") is designed to allow you (the "Principal") to appoint someone you trust, referred to as an "Agent," to make health care decisions on your behalf should you become unable to make them yourself. This Document complies with the Oklahoma Advance Directive Act (Oklahoma Statutes, Title 63, §3101.4).
By completing and signing this Document, your Agent will have the legal authority to speak with your health care providers, review medical records, and make critical medical decisions based on your wishes and in your best interest.
Principal Information
Please fill in your information accurately:
- Full Name: ___________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Date of Birth: ________________________
- Telephone Number: ____________________
Agent Information
Designate your Agent by listing their information below:
- Agent's Full Name: ___________________________
- Relation to Principal: ________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Primary Telephone Number: _______________
- Alternate Telephone Number: ______________
Alternate Agent Information
If your primary Agent is unavailable, designate an Alternate Agent:
- Alternate Agent's Full Name: ___________________________
- Relation to Principal: ________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Primary Telephone Number: _______________
- Alternate Telephone Number: ______________
By signing below, you affirm that you understand the nature and purpose of this Document and the authority you are granting to your Agent. You also affirm that you are executing this Document voluntarily, without duress or undue influence.
Principal's Signature
______________________________________________
Date: _______________
Agent's Acknowledgment
I, ____________________________ (Agent), hereby accept the appointment and agree to serve as Agent to make health care decisions for the Principal as described in this Oklahoma Medical Power of Attorney. I understand that this role requires me to act in the Principal’s best interests, in accordance with Oklahoma law.
Agent's Signature: ____________________________
Date: _______________
Alternate Agent's Acknowledgment
I, ____________________________ (Alternate Agent), hereby accept the appointment and agree to serve as Alternate Agent to make health care decisions for the Principal as described in this Oklahoma Medical Power of Attorney, in the event the original Agent is unable or unwilling to serve.
Alternate Agent's Signature: ____________________________
Date: _______________
Note: It is strongly recommended to have this Document notarized and/or witnessed to enhance its legal standing.
This Document should be provided to your healthcare providers, your Agent, and any relevant healthcare facilities to ensure your wishes are followed.