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Colorado Name ________________________________________________________ Address ______________________________________________________ -2- olorado, this ______ day of ________, 20 ____. (city) (day) (month) (year) Name ________________________________________________________ Address ______________________________________________________hat, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence. Dated at _____________, Cof declarant) her declaration, in the presence of us, who, in his or her presence, in the presence of each other, and at his or her request, have signed our names below as witnesses, and we declare t By ______________________________________ (signature of declarant) WITNESSES The foregoing instrument was signed and declared by ________________________________________________ to be his or (name it is the only procedure being provided. -1- 3. Other directions: 4. I execute this declaration, as my free and voluntary act, this ______ day of (day) ___________________, 20 ___. (month) (year)procedure being provided; or _____ b. Artificial nourishment shall be continued for ____ days when it is the only procedure being provided; or _____ c. Artificial nourishment shall be continued wheng provided is artificial nourishment, I direct that one of the following actions be taken: (initial the option that applies) _____ a. Artificial nourishment shall not be continued when it is the only specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration. 2. In the event that the only procedure I am beinlife-sustaining procedures shall not include any medical procedure or intervention for nourishment considered necessary by the attending physician to provide comfort or alleviate pain. However, I may ncerning my person, then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration, it being understood that erminal condition, and b. For a period of seven consecutive days or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsible decisions co time my attending physician and one other qualified physician certify in writing that: a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a t_, (name) being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that: 1. If at any__________________________________________ Date ___________________________ -3- Colorado Declaration as to Medical or Surgical Treatment I, _________________________________________________________________________ Date ___________________________ Second Witness' Signature ________________________________________ Home Address _________________________________________________ Print Name _________health care provider. First Witness' Signature __________________________________________ Home Address _________________________________________________ Print Name ____________________________________ of sound mind and under no duress, fraud or undue influence. I am not the person appointed as the agent by this document, nor am I the patient's health care provider, or an employee of the patient's t the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Medical Durable Power of Attorney in my presence, and that he/she appears to be_____________________________________ (address) _____________________________________________________________ (signature of person creating Medical Durable Power of Attorney) WITNESSES I declare thaions: -2- BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT. I sign my name to this form on: __________________ at:_______________ (date) ________________________e his/her decisions on what he/she believes to be in my best interest. (a) Statement of desires concerning life-prolonging care, treatment, services and procedures: (b) Special provisions and limitat agent shall make health care decisions as I may direct below or as I make known to him or her in some other way. If I have not expressed a choice about the health care in question, my agent shall bas- By this document I intend to create a Medical Durable Power of Attorney which shall take effect upon my incapacity to make my own health care decisions and shall continue during that incapacity. Myate) ______________________________________________________________ (home address) ______________________________________________________________ (work telephone number) (home telephone number). -1) _____________________________________________________________ (work telephone number) (home telephone number) 2. ____________________________________________________________ (name of second alterno serve in the order listed below: 1. ___________________________________________________________ (name of first alternate) _____________________________________________________________ (home addressformation and sign forms necessary to carry out those decisions. If the person named as my agent is not available or is unable or unwilling to act as my agent, then I appoint the following person(s) tmy agent the power to consent to giving, withholding or stopping any health care, treatment, service or diagnostic procedure. My agent also has the authority to talk with health care personnel, get in__________ (work telephone number of agent) (home telephone number of agent) as my agent to make health care decisions for me if and when I am unable to make my own health care decisions. This gives ____________________________________________ (name of agent) _____________________________________________________________ (home address of agent) ___________________________________________________rs and Terms of Use found at findlegalforms.com Colorado Medical Durable Power of Attorney for Health Care I, ______________________________________________, hereby appoint: (name) _________________o make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. The purchase and use of these forms is subject to the Disclaimeate. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it thich is somewhat similar to a living will) . It is made up for use in Colorado. These forms are not intended and are not a substitute for legal advice. Laws vary from time to time and from state to stInformation on Colorado Health Care Directive This package contains a (1) Colorado Medical Durable Power of Attorney for Health Care and (2) Colorado Declaration as to Medical or Surgical Treatment (w Colorado