HEALTH CARE PROXY (1) I, ____________________________________________________________________________ hereby appoint___________________________________________________________________ _________________________________________________________________________________ (name, home address and telephone #) as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect when and if I become unable to make my own health care decisions. (2) Optional Instructions: I direct my agent to make health care decisions in accord with my wishes and limitations as stated below, or as he or she otherwise knows (Attach additional pages as necessary)______________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ (3) Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes), your agent will not be allowed to make decisions regarding this.I have discussed my wishes about artificial nutrition and hydration with my proxy (   ) Yes (   )  No If no, my wishes are________________________________________________________________ _________________________________________________________________________________ (4) Name of substitute or fill-in agent if the person above is unable, unwilling or unavailable to act as my health care agent: _________________________________________________________________________________ (name, address and phone #) (5) Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions stated:  _________________________________________________________________________ (6) Signature:_____________________________________________________________________ Address__________________________________________________________________________ Date_____________________________________________________________________________ Statement by Witness (must be 18 years of age or older; not an assigned proxy agent): I declare that the person who signed this document is known to me and appears to be of sound mind and acting of his or her own free will. He or she signed this document in my presence. Witness #1:_______________________________________________________________________ Address__________________________________________________________________________ Witness #2_______________________________________________________________________ Address__________________________________________________________________________ Please carry a copy of this health care proxy with you in your wallet.