Health Care Proxy – Example

Do not use without consulting an attorney in your state.

Last reviewed 09-03-2023

Health Care Proxy

( 1) I, (First name, Last Name), hereby appoint (First name, Last name), living at (street, city, state, zip code) and primary phone number (telephone number), as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional Instructions: I direct my agent to make any and all health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary).

(3) Name of substitute of back up agent if the person I appoint is unable, unwilling, or unavailable to act as my health care agent.

 Back Up Agent: (name, home address and telephone number):

(4) Unless I revoke it, this proxy shall remain in effect indefinitely or until the date or conditions stated below. This proxy shall expire (specify date or conditions, if desired):

(5) Print Name: (First Name, Last Name)


Address: (Street, city, zip code)


(6) Optional: Organ and/or Tissue Donation
I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)
__ Any needed organs and/or tissues.

__ The following organs and/or tissues:


If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Signature: (First Name, Last Name)



Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.) I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.

Witness 1: (First Name, Last Name)

Witness 1 Address: (Street, city, zip code)

Witness 2: (First Name, Last Name)

Witness 2: Address: (Street, City, zip code)