Special Power of Attorney for Medical Authorization
I, ___________(1)___________, of __________(2)_________, hereby
appoint ______________(3)________________ of ___________(4)_______________,
as my attorney in fact to act in my capacity to do any and all of
1. Make any and all decisions and authorize all procedures that
_____(5)____ may deem necessary regarding the medical treatment
of my children, _____(6)_____ and/or ______(7)______.
The rights, powers, and authority of my attorney in fact to exercise
any and all of the rights and powers herein granted shall commence
and be in full force and effect and shall remain in full force and
effect until ___________(8)_______________ or unless specifically
extended or rescinded earlier by either party.
Dated ___________(9)______________, 19_(10)_.
STATE OF _______(12)____________
COUNTY OF ______(13)____________
BEFORE ME, the undersigned authority, on this _(14)_ day of _______(15)________,
19_(16)_, personally appeared ___________(17)___________ to me well
known to be the person described in and who signed the Foregoing,
and acknowledged to me that he executed the same freely and voluntarily
for the uses and purposes therein expressed.
WITNESS my hand and official seal the date aforesaid.
__________(18)_________________ NOTARY PUBLIC
My Commission Expires:__(19)___
The information in this document is designed to provide an outline
that you can follow when formulating business or personal plans. Due
to the variances of many local, city, county and state laws, we recommend
that you seek professional legal counseling before entering into any
contract or agreement.