Louisiana Medical Power of Attorney
This Medical Power of Attorney is established in accordance with the relevant provisions under Louisiana law. It empowers a designated agent to make healthcare decisions on behalf of the principal (the person creating the Medical Power of Attorney) in the event that the principal is unable to make decisions or communicate their wishes regarding medical treatment.
Principal Information:
- Full Name: ___________________________________________
- Date of Birth: ________________________________________
- Address: _____________________________________________
Agent Information:
- Full Name: ___________________________________________
- Relationship to Principal: _____________________________
- Primary Phone Number: ________________________________
- Alternate Phone Number: ______________________________
- Email Address: _______________________________________
- Address: _____________________________________________
Alternate Agent Information (if primary agent is unable or unwilling to serve):
- Full Name: ___________________________________________
- Relationship to Principal: _____________________________
- Primary Phone Number: ________________________________
- Alternate Phone Number: ______________________________
- Email Address: _______________________________________
- Address: _____________________________________________
In the event my designated agent is unable or unwilling to serve, I authorize my alternate agent to make health care decisions for me as described in this document.
Special Instructions:
In making health care decisions, my agent should consider the following special instructions (if any):
Duration:
This Medical Power of Attorney becomes effective immediately upon my incapacity to make my own healthcare decisions and will remain in effect until my death, unless I choose to revoke it sooner.
Signature:
Principal's Signature: _________________________________ Date: ____________
Agent's Signature: ____________________________________ Date: ____________
Alternate Agent's Signature: ___________________________ Date: ____________
The signatures above indicate the understanding and agreement of each party to the provisions included in this Louisiana Medical Power of Attorney.
Witnesses:
- Witness Name: _______________________________________
- Witness Signature: _________________________________
- Witness Name: _______________________________________
- Witness Signature: _________________________________
This document was signed in front of witnesses, as required by Louisiana state laws governing Medical Power of Attorney agreements.