Florida Medical Power of Attorney
This Medical Power of Attorney is created in accordance with Florida law.
Principal Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip Code: _______________
- Date of Birth: _______________________
Agent Information:
- Name: ______________________________
- Address: ____________________________
- City, State, Zip Code: _______________
- Phone Number: ______________________
I, the undersigned, hereby appoint the individual named above as my agent to make healthcare decisions on my behalf if I am unable to make those decisions myself.
Purpose:
This document grants the agent authority to make medical decisions regarding:
- Medical treatment
- Surgical procedures
- Medication administration
- End-of-life care
- Access to medical records
Effective Date:
This Medical Power of Attorney becomes effective when I am unable to make my own healthcare decisions, as determined by a qualified medical professional.
Signature:
By signing below, I confirm that I understand the contents of this document and that I am willingly granting my agent the authority to make medical decisions on my behalf.
Signature of Principal: ________________________
Date: ______________________________________
Witness Declaration:
I, the undersigned witness, affirm that the Principal appeared to be of sound mind and capable of understanding the nature of this document at the time of signing.
Witness 1 Name: _____________________________
Signature: __________________________________
Date: ______________________________________
Witness 2 Name: _____________________________
Signature: __________________________________
Date: ______________________________________