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Colorado e Address _________________________________________________ Print Name ___________________________________________________ Date ___________________________ -3- ________________________________ Print Name ___________________________________________________ Date ___________________________ Second Witness' Signature ________________________________________ Homt, nor am I the patient's health care provider, or an employee of the patient's health care provider. First Witness' Signature __________________________________________ Home Address _________________ Medical Durable Power of Attorney in my presence, and that he/she appears to be of sound mind and under no duress, fraud or undue influence. I am not the person appointed as the agent by this documene of person creating Medical Durable Power of Attorney) WITNESSES I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this form on: __________________ at:_______________ (date) _____________________________________________________________ (address) _____________________________________________________________ (signaturng care, treatment, services and procedures: (b) Special provisions and limitations: -2- BY SIGNING HERE I INDICATE THAT I UNDERSTAND THE PURPOSE AND EFFECT OF THIS DOCUMENT. I sign my name to thisave not expressed a choice about the health care in question, my agent shall base his/her decisions on what he/she believes to be in my best interest. (a) Statement of desires concerning life-prolongi make my own health care decisions and shall continue during that incapacity. My 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 h__________________________ (work telephone number) (home telephone number). -1- By this document I intend to create a Medical Durable Power of Attorney, which shall take effect upon my incapacity to________________________________________________________ (name of second alternate) ______________________________________________________________ (home address) ____________________________________e) _____________________________________________________________ (home address) _____________________________________________________________ (work telephone number) (home telephone number) 2. ____nable or unwilling to act as my agent, then I appoint the following person(s) to serve in the order listed below: 1. ___________________________________________________________ (name of first alternature. My agent also has the authority to talk with health care personnel, get information and sign forms necessary to carry out those decisions. If the person named as my agent is not available or is uor me if and when I am unable to make my own health care decisions. This gives my agent the power to consent to giving, withholding or stopping any health care, treatment, service or diagnostic proced__ (home address of agent) _____________________________________________________________ (work telephone number of agent) (home telephone number of agent) as my agent to make health care decisions f____________________________________, hereby appoint: (name) _____________________________________________________________ (name of agent) ___________________________________________________________ another party. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Colorado Medical Durable Power of Attorney for Health Care I, __________. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated witha substitute for legal advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney firstInformation Colorado Medical Durable Power of Attorney for Health Care This package contains a (1) Colorado Medical Durable Power of Attorney for Health Care. These forms are not intended and are not Colorado