New Jersey Medical Power of Attorney Form

The following form can be used for choosing someone to act on your behalf in any health care-related decision in case you were unable to speak for yourself.

Extracted Text for Proper Search

NewJer sey Medi cal Power OfAtto rney	
I,__ ___ ___________ ____ ___ _____ _____ _____ _____ _____ _____ ____ _____ ____________________________________,residing at
_____ ____________ _______ _____ _____ _____ _______ _____ _________ ______________________________________,as princi pal,
hereby desi gna teand app oint_ _____ _____ _______ _____ _____ ____ _____ ____________________________________,residing at
_____ ____________ _______ _____ _____ _____ _______ _____ _________ ______________________________________,as my agent
forallma tter srel ating to my healt hcare including, butnot limi ted to,full power togive, refuseorrevo keconsent to all medical,
surg ical an dhosp ita lca re. Specifica lly,Iautho rizemyagent toord er therefu sal, discontinuation orwithdrawal ofall forms of
lifes ustai ning treatm ent ifmyagent determine sth at base dupon his\fher knowl edge ofmyperso nalinstructions, beliefs,and
value syste mIwo uld not wan tto have such treatm ent institu tedor continued. Thispower ofattorney shallnotbeaffected by
anydisa bility of theprinc ipal.
Sign ed,sea led an ddeliver edinthe presence of:
AgentÕ sSigna ture
State of New Jer sey \b
\bss.:
County of \b
BE IT REMEMBE REDTHATON THIS _____ _______ _____ ____ day of______ ___________________, 20_____ _,before methe
subscrib er,a Nota ryPub licof New Jersey, persona llyapp eared______ __________ ________,whoIam satisfied isthe person
named in and wh oexecu tedthewithin Power ofAttorn eyand_he acknowledged that_hesigned, sealedanddelivered said
Power ofAttorn eyas his\fher voluntaryact and dee d,forthe usesand purposes therein expresse d.
NotaryPub lic	
P rinci palÕs Si gna tur e