Publications
Form for Appointment of Health Care Agent
APPOINTMENT OF HEALTH CARE AGENT
I appoint _________________________(NAME) to be my health care agent. If my attending physician determines that I am unable to understand and appreciate the nature and consequences of health care decisions and to reach and communicate an informed decision regarding treatment, my health care agent is authorized to:
- Convey to my physician my wishes concerning the withholding or removal of life support systems.
- Take whatever actions are necessary to ensure that my wishes are given effect.
If this person is unwilling or unable to serve as my health care agent, I appoint _____________________________(NAME) to be my alternative health care agent.
This request is made, after careful reflection, while I am of sound mind.
_____________________________(SIGNATURE)
___________________________________(DATE)
Witness Statements
This document was signed in our presence, by the above-named _______________________________ (NAME) who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed.
__________________________________(NAME)
_______________________________(ADDRESS)
__________________________________(NAME)
_______________________________(ADDRESS)
(NOTE: THIS FORM IS OPTIONAL)
STATE OF CONNECTICUT )
: ss. (Town)
COUNTY OF ____________ )
We, the undersigned, being duly sworn, depose and say:
That on this date, the within named __________________________, signed the foregoing appointment of health care agent in our presence as witnesses; that we thereupon subscribed our names thereto as witnesses in (his/her) presence and at (his/her) request, and in the presence of each other; that at the time of the execution of said appointment of health care agent the said ________________ appeared to be more than eighteen years of age and of sound mind and memory, and to the best of our judgment not under any improper restraint or influence or in any respect incompetent to make an appointment of health care agent; and that we make this affidavit at (his/her) request this _____ day of ______________________, 200 __.
___________________________________
___________________________________
Subscribed and sworn to before me, on this _____ day of ________, 200__.
___________________________________
Notary Public
Commissioner of Superior Court