Vermont Medical Power of Attorney Form

In the State of Vermont, a resident must fulfill this form if s/he wants to appoint another person as her/his representative in medical matters. Use of this form is endorsed to individuals expecting the loss of their decision-making function later in life.Download

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Durable Power of Attorney for Health Care Vermont  
Standard Form 
(Please print clearly, except where signature is required) 
 
I, …………………………\05………………205\25…205….. of …205…205…\05…205205\25…....…205., hereby appoint 
…205205\20…\05…\05…\25…\25…\20…\25\25…205205 of …205205…205205…\05\05\20…\20….., as my agent to make any 
and all health care decisions for me, except to the extent I state otherwise in this document. This durable 
power of attorney for health care shall take effect in the event I become unable to make my own health 
care decisions. Should the person I have appointed be unable, unwilling or unavailable to act as my 
health care agent, I hereby appoint  
 
........................................... of …205205205\25\25…\05\05…205205205\20……205. as my 
alternate agent. 
 
A. STATEMENT OF DESIRES, SPECIAL PROVISIONS AND LIMITATIONS REGARDING HEALTH 
CARE DECISIONS. Here you may include any specific desires or limitations you feel are appropriate, 
such as when or what life-sustaining measures should be started or withheld; directions whether or not to 
use artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are 
inconsistent with your religious beliefs or unacceptable to you for any other reason. (If you want to include 
instructions about life-sustaining treatment, read Part B before filling out this section.) (attach additional 
worksheets or pages as necessary) 
 
 
 
 
 
 
 
 
 
B. THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR IMPORTANCE. For 
your convenience in dealing with this subject, some general statements concerning life-sustaining 
treatment are set forth below. IF YOU AGREE WITH ONE OF THE STATEMENTS, YOU MAY COPY IT 
IN THE SPACE PROVIDED ABOVE. 
1. If I suffer a condition from which there is no reasonable prospect of regaining my ability to think 
and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to 
decline all treatment (including artificial nutrition and hydration) the primary purpose of which is to 
prolong life. 
 
2. If I suffer a condition from which there is no reasonable prospect of regaining the ability to think 
and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition 
and hydration, if needed, but authorize my agent to decline all other treatment the primary purpose 
of which is to prolong my life. 
 
3. I want my life sustained by any reasonable medical measures, regardless of my condition.

Durable Power of Attorney for Health Care  - Vermont 
Page 2 
 
 
I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this 
document. I have read, or had read to me, and understand the information contained in the disclosure 
statement. The original of this document will be held by my agent, and photocopies of the original will be 
given to my alternate agent and the following: 
 
______________       __________ 
 
_________      ___________ 
 
__________       ___________ 
 
 
In witness whereof, I have hereunto signed my name this date of ……………………, 20…. 
 
Signature …205……………\25…205………205…205……. Date of Birth …205205\25………205205…  
 
Address ……………\25…\25…\20……\05\20…\25\25…205205…205205……\05…205205205\25\25……\05 
 
I declare that the principal appears to be of sound mind and free from duress at the time the durable 
power of attorney for health care is signed and that the principal has affirmed that he or she is aware of 
the nature of the document and is signing it freely and voluntarily. 
 
 
Witness: …\25\25…\25\25…\20…\20……205205.. Address: …\20\20……\05……\05…\25\25\25…205.  
 
Witness: …205205205\20\20…\25\25\25……\05\05.. Address: …205205205…205205205……\05\05…205205. 
 
 
The following is required only if this document is being signed while the principal is in or being admitted to 
a hospital, nursing home or residential care home. 
 
Statement of ombudsman, hospital representative, recognized member of the Vermont clergy, Vermont-
licensed attorney or other person designated by the county Probate Court: I declare that I have personally 
explained the nature and effect of this durable power of attorney to the principal and that the principal 
understands the same. 
 
Date: ……\05\05……. 
 
Name: …\25\25\25…\25\25\25…\20\20…\20\20…….. Address: …\20\20\20……\05\05…\25\25\25\25….