Virginia Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the Virginia Health Care Decisions Act, empowering an individual to make health care decisions on behalf of the principal when they are unable to do so.
Principal’s Information
Full Name: ___________________________
Date of Birth: ________________________
Address: _____________________________
Agent’s Information
Full Name: ___________________________
Relationship to Principal: _____________
Primary Phone: ________________________
Alternate Phone: ______________________
Email Address: ________________________
Address: _____________________________
Alternate Agent’s Information (Optional)
Full Name: ___________________________
Relationship to Principal: _____________
Primary Phone: ________________________
Alternate Phone: ______________________
Email Address: ________________________
Address: _____________________________
In the event that my primary agent is unable or unwilling to serve, I designate the above-named alternate agent to act on my behalf.
Authority Granted to Agent
The agent is authorized to make all forms of health care decisions on my behalf that I could make myself, should I become incapable of making an informed decision regarding my health care, except as I may otherwise limit:
- Consent or refusal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition.
- To choose or discharge health care providers and institutions.
- To refuse or consent to the creation, maintenance, disclosure, or release of any health information pertaining to me.
- To make decisions regarding autopsy and organ donation.
Specific Limitations
If there are any specific limitations on the agent's power, describe them here: __________________________________________
__________________________________________________________________________________________________________________
Duration
This Medical Power of Attorney shall become effective immediately upon the incapacity of the principal and will remain in effect until the principal is again able to participate in medical decisions.
Signature and Acknowledgment
Principal’s Signature: _____________________ Date: _________________
Agent’s Signature: ________________________ Date: _________________
Alternate Agent’s Signature (If applicable): _____________________ Date: _________________
This document was signed in the presence of two subscribing witnesses, not related by blood or marriage to the principal, and not entitled to any portion of the estate of the principal under any will or codicil.
Witness 1 Signature: _____________________ Date: _________________
Witness 2 Signature: _____________________ Date: _________________