North Carolina Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with the laws of the State of North Carolina. It allows you to appoint an agent to make healthcare decisions on your behalf if you are unable to do so.
Principal Information:
- Name: ________________________________
- Address: ______________________________
- City, State, Zip: ______________________
- Date of Birth: _________________________
Agent Information:
- Name: ________________________________
- Address: ______________________________
- City, State, Zip: ______________________
- Phone Number: _________________________
Alternate Agent Information:
- Name: ________________________________
- Address: ______________________________
- City, State, Zip: ______________________
- Phone Number: _________________________
Effective Date: This Medical Power of Attorney shall become effective when I am unable to make my own healthcare decisions.
Healthcare Instructions:
In the event that I am unable to communicate my healthcare wishes, I direct my agent to make decisions based on my preferences. If I have not expressed a preference, my agent should consider the following:
- My values and beliefs.
- My past medical history and treatment preferences.
- Consultation with my healthcare providers.
Signature:
I, ________________________________, the undersigned, hereby appoint the above-named agent to act on my behalf in making healthcare decisions in accordance with this document.
Signature of Principal: ________________________________
Date: ________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness Name: ________________________________
- Witness Signature: ________________________________
- Date: ________________________________
- Witness Name: ________________________________
- Witness Signature: ________________________________
- Date: ________________________________
Notary Public:
State of North Carolina
County of ________________________________
Subscribed and sworn to before me this _____ day of ____________, 20__.
Notary Signature: ________________________________
My Commission Expires: ________________________