Preview - Medical Proxy Service Form

Medical Proxy
Service Form

Please fill out the form in its entirety.

PLEASE TYPE AS CLEARLY AS POSSIBLE TO ENSURE A BETTER UNDERSTANDING OF YOUR ANSWERS.

SECTION 1. MEDICAL PROXY

GRANTOR

Please type your FULL NAME (as it appears in your passport)*

Civil Status*

Passport or Cedula Number*

Nationality*

Email*

Full Address*

Describe motive for granting the medical proxy and medical wishes.*

MEDICAL REPRESENTATIVE/PROXY

Person who will express your will, as established under this document, in case you are physically unable to express your will.

Full Legal Name (as shown in ID or Passport):*

Civil Status*

Passport or Cedula Number*

Nationality*

Full Address*

Primary Contact Number*

Secondary Contact Number

Optional but recommended

Primary Contact Email*

Secondary Contact Email

Optional but recommended

REPLACEMENT MEDICAL REPRESENTATIVE/PROXY

Who will become your medical proxy in case of physical absence of the primary Representative/Proxy.

Full Legal Name (as shown in ID or Passport):*

Civil Status*

Passport or Cedula Number*

Nationality*

Full Address*

SPECIFIC WISHES

Pacemakers*

Device that substitutes the normal heartbeat.

Yes
No

Respirator / Ventilator*

Breathing machine connected to a tube that is inserted in the lungs through the nose and mouth.

Yes
No

Cardiopulmonary Resuscitation (CPR)*

Intervention made by a person or machine or medicine when the heart and/or lungs stop functioning.

Yes
No

Feeding Tube*

Tube that is placed in the stomach or intestines to provide liquids and/or nutrition.

Yes
No

Intravenous (IV)*

Lines for medicine and care of conformity.

Yes
No

Administration of Antibiotic*

Substance for the treatment of pneumonia and other infections.

Yes
No

Radiation Therapy*

Yes
No

Transfusions*

Blood or Blood Derivates administered through IV.

Yes
No

Testing and procedures to monitor failure conditions*

Yes
No

Administration of Tylenol/Aspirin*

If used to reduce fever, might prolong the process of death.

Yes
No

Organ Donation*

Yes
No

*

Science
Other Patients

Procedure and diagnostic tests, Surgeries and other considerations*

Yes
No

Dialysis Procedure*

Elimination process for excess of water, solutions, and toxins from the blood in persons whose kidneys no longer function in a natural way.

Yes
No

Chemotherapy Procedure*

Pharmacological treatment that utilizes strong chemical products to kill the fast-growing cells in the body.

Yes
No

SECTION 2. REVIEW AND SUBMIT

Please review the information you have entered and verify all information is correct.

Once submitted, the service will be processed by the Firm and once the Deed is filed, any changes to it will be subject to a surcharge.

*

I have read and agree to the disclaimers and notices.
I have reviewed the information provided in this form

PDF Name

FORM PREVIEW

FORM PREVIEW

Medical Proxy Service Form

SECTION 1. MEDICAL PROXY

GRANTOR

MEDICAL REPRESENTATIVE/PROXY

REPLACEMENT MEDICAL REPRESENTATIVE/PROXY

SPECIFIC WISHES

SECTION 2. REVIEW AND SUBMIT

Medical Proxy
Service Form