Advance Healthcare Directive
1. Personal Information
First name / Last name: [[FIRST_NAME_1]] [[LAST_NAME_1]]
Date of birth: [[DATE_OF_BIRTH_1]]
Address: [[ADDRESS_1]]
2. Purpose of this Advance Healthcare Directive
This advance healthcare directive applies if I am no longer capable of making decisions and can no longer make medical decisions for myself.
With this document, I:
• set out my wishes regarding medical treatment
• appoint a representative
• may appoint an alternate representative
3. Representative
I appoint the following person as my representative for medical decisions:
First name / Last name: [[FIRST_NAME_2]] [[LAST_NAME_2]]
Date of birth: [[DATE_OF_BIRTH_2]]
Address: [[ADDRESS_2]]
Telephone: [[TELEPHONE_1]]
Email: [[EMAIL_1]]
My representative may speak with doctors, hospitals, care institutions, and other medical
professionals and make decisions on my behalf if I am no longer able to do so myself.
They shall decide according to my wishes and in my best interests.
4. Alternate Representative
If my representative cannot be reached or is unable or unwilling to take on this role, I appoint the
following person as my alternate representative:
First name / Last name: [[FIRST_NAME_3]] [[LAST_NAME_3]]
Date of birth: [[DATE_OF_BIRTH_3]]
Address: [[ADDRESS_3]]
Telephone: [[TELEPHONE_2]]
Email: [[EMAIL_2]]
5. Personal Wishes and Values
The following points are particularly important to me regarding my medical treatment:
[[PERSONAL_WISHES]]
[[ADDITIONAL_WISHES]]
Vollständiger Zugriff nach Zahlung