Vermont Medical Power of Attorney
This Vermont Medical Power of Attorney is a legal document designed under the Vermont Patients' Bill of Rights Act that allows an individual (hereafter referred to as the "Principal") to designate another person (hereafter referred to as the "Agent") to make healthcare decisions on their behalf in the event they are unable to communicate or make decisions for themselves.
Principal Information
Full Name: ___________________________
Date of Birth: ________________________
Address: ______________________________
_______________________________________
Phone Number: ________________________
Agent Information
Full Name: ___________________________
Relationship to Principal: ________________
Address: ______________________________
_______________________________________
Phone Number: ________________________
Alternate Agent Information (Optional)
If the primary Agent is unable or unwilling to serve, the Alternate Agent will assume the role. It is not mandatory to appoint an Alternate Agent.
Full Name: ___________________________
Relationship to Principal: ________________
Address: ______________________________
_______________________________________
Phone Number: ________________________
By signing this document, the Principal grants the Agent full power and authority to make healthcare decisions on their behalf, including but not limited to:
- Selection or change of healthcare providers and institutions
- Approval or refusal of diagnostic tests, surgical procedures, and programs of medication
- Directions to provide, withhold, or withdraw life-sustaining treatments and artificial nutrition and hydration
- Access to medical records
This power of attorney becomes effective immediately upon the incapacity of the Principal, as determined by a physician. The authority granted in this document will remain in effect until the Principal's death, unless the Principal revokes it sooner.
Signatures
This document must be signed by the Principal, the Agent, and an Alternate Agent (if one is designated), in the presence of two witnesses or a notary public. The witnesses must not be related to the Principal by blood, marriage, or adoption and must not be entitled to any portion of the estate of the Principal under any will or codicil.
Principal's Signature: ___________________________ Date: _________
Agent's Signature: ______________________________ Date: _________
Alternate Agent's Signature (If Applicable): ___________________________ Date: _________
Witness 1 Signature: ___________________________ Date: _________
Witness 2 Signature: ___________________________ Date: _________
Notary Public (If Applicable): ___________________________ Date: _________
It is recommended that this document be reviewed regularly and kept in a safe place where it is accessible to the Agent.