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Submit Your Durable Power of Attorney For Health Care Information Online

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Who do you appoint as your agent to make health care decisions for you in the event you become unable?

Do you wish for your agent to consent to voluntary inpatient mental heath services, convulsion treatment or physical surgery?

In the event of your primary agent becomes unable or unwilling to make these decisions, name a first alternate agent. (This is recommended, but optional)

In the event your primary agent and first alternate agent become unavailable or unwilling to make these decisions, name a second alternate agent. (This is recommended, but optional)

Do you wish the original documents to be kept at the offices of Dickinson, Wheelock, Smith and Cerasuolo? There is no charge for keeping these records. A copy of the documents will be provided for you.

Do you have any previous durable power of attorney for health care?

Do you wish to revoke any previous durable power of attorney for health care?


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