PATIENT SELF DETERMINATION ACT QUESTIONNAIRE

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DON’T LOSE YOUR RIGHT TO DECIDE!

You cannot remove all uncertainty about your future healthcare needs but by having an advanced directive you can have the peace of mind that comes from making your wishes known in advance!

If you have indicated that you have a living will, Healthcare Surrogate and/or a Durable Power of Attorney, please bring the fully executed document to your next visit so we can add it as part of your medical records.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

If you have any further questions, you can contact your family attorney, local hospital, or local medical association for additional information.

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