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SPECIAL POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION
SPECIAL POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION
I, _____________________, of ___________________, hereby appoint ______________________________
of __________________________, as my attorney in fact to act in my capacity to do any and all of the following: 1. Make any and all decisions and authorize all procedures that _________ may deem necessary regarding the medical
treatment of my children, __________ and/or ____________. The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted
shall commence and be in full force and effect and shall remain in full force and effect until __________________________ or
unless specifically extended or rescinded earlier by either party. Dated _________________________, 19__. __________________________ STATE OF ___________________ COUNTY OF __________________ BEFORE ME, the undersigned authority, on this __ day of _______________, 19__, personally appeared
______________________ to me well known to be the person described in and who signed the Foregoing, and acknowledged to me
that he executed the same freely and voluntarily for the uses and purposes therein expressed. WITNESS my hand and official seal the date aforesaid. ___________________________ My Commission Expires:_____ NOTICE
NOTARY PUBLIC
The information in this document is designed to provide an outline that you can follow when formulating business or personal plans.
Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before
entering into any contract or agreement.