Oregon Medical Power of Attorney
This document grants authority to a designated individual, referred to as the Agent, to make medical decisions on behalf of the person signing the document, known as the Principal, in the event that the Principal is unable to make decisions or communicate their wishes regarding their medical treatment. This document is governed by and construed in accordance with the laws of the State of Oregon.
Principal Information:
- Full Name: _______________________________________________________________
- Address: __________________________________________________________________
- Date of Birth: _____________________________________________________________
- Social Security Number (optional): __________________________________________
Agent Information:
- Full Name: _______________________________________________________________
- Address: __________________________________________________________________
- Phone Number: ____________________________________________________________
- Email Address: ____________________________________________________________
Alternate Agent Information (in the event the primary Agent is unable, unwilling, or unavailable to act):
- Full Name: _______________________________________________________________
- Address: __________________________________________________________________
- Phone Number: ____________________________________________________________
- Email Address: ____________________________________________________________
Authority of Agent: The Agent is authorized to make all forms of medical decisions on behalf of the Principal that the Principal could make if capable, including but not limited to: receiving medical histories, consenting or refusing medical treatment, and gaining access to medical records.
Limitations on Agent's Authority: The authority of the Agent is subject to the following limitations (if any): ___________________________________________________________.
Effective Date and Duration: This document becomes effective immediately upon the incapacity of the Principal to make decisions and remains in effect until the Principal regains the ability to make decisions, revokes the power granted herein, or upon the death of the Principal.
Attestation of Principal:
I, the undersigned Principal, declare that I fully understand the contents of this document and willingly grant the authority specified herein to the named Agent.
- Principal's Signature: ___________________________________ Date: _________________
- Print Name: _________________________________________________________________
Attestation of Witnesses: (According to Oregon law, the signing of this document must be witnessed by two individuals who are neither the Agent nor related to the Principal by blood, marriage, or adoption, and not directly financially responsible for the Principal's medical care.)
- Witness 1 Signature: _________________________________ Date: _________________
- Print Name: _________________________________________________________________
- Witness 2 Signature: _________________________________ Date: _________________
- Print Name: _________________________________________________________________
State of Oregon Notarization (if applicable):
This section to be completed by a notary public: __________________________________
Notary Public Signature: ___________________________________ Date: _______________
My commission expires: ________________________________________________________