MEDICAL POWER OF ATTORNEY FOR COVID 19 OR VARIANTS

MEDICAL POWER OF ATTORNEY FOR COVID 19 OR VARIANTS

STATE OF ______________ §

§ KNOW ALL MEN BY THESE PRESENTS

COUNTY OF ____________ §

I, _______________, appoint

Name:
Address:
Phone:

as my agent(s) to make any and all health care decisions for me, except to the extent I state otherwise in this document. The agents listed above can work together or if needed in an attorney client capacity. This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS:

This Power of Attorney specifically is to be used for the limited purpose of determining treatment options associated with a Covid 19, variants or illnesses derived thereof diagnosis or for the treatment of side effects from vaccines associated with Covid 19 or its variants.

DESIGNATION OF ALTERNATE AGENT

If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following person to serve as my agent to make health care decisions for me as authorized by this document:

Name:

Address:

Phone:

DURATION.

I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.

This Covid19 related Medical Power of Attorney is in effect for one year from the date of signature below.

DISCLOSURE STATEMENT.

THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:

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