As my attorney-in-fact to make any and all health care decisions for me, except to the extent I state otherwise in this document. This Medical Power of Attorney takes effect if I become unable to make my own health care decisions and my physician certifies this fact in writing. The following are limitations on the decision making authority of my agent:

If the above designated person as my agent is unable or unwilling to make healthcare decisions for me, I hereby designate the following persons to serve as my agent to make health care decisions for me as is authorized by this document, who may serve in the following order:

This power of attorney is to start to be effective on ____/____/______, and shall remain effective until ____/____/______. 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. I hereby revoke any prior Medical Power of Attorney that I have made in the past. I do hereby grant my attorney-in-fact complete and full authority to act in any reasonable and necessary manner for the purpose of exercising the above mentioned powers. I also, ratify all the lawfully performed acts by my attorney-in-fact in exercising those powers. I fully understand and agree that any third party who is given a copy of this Power of Attorney may act relying on it. I also, agree that revocation of this Power of Attorney is effective as to a third party only when they receive receipt of an actual notice by the third party. If due to reliance on the Power of Attorney, a third party suffers any loss, I agree to pay for any third party loss.