Oregon Medical Power of Attorney
This document allows you to appoint someone to make medical decisions on your behalf in Oregon, as permitted by Oregon state law.
Principal Information:
- Full Name: ____________________________________
- Address: ________________________________________
- City, State, Zip: ________________________________
- Date of Birth: __________________________________
Agent Information:
- Full Name: ____________________________________
- Address: ________________________________________
- City, State, Zip: ________________________________
- Phone Number: _________________________________
Alternate Agent (optional):
- Full Name: ____________________________________
- Address: ________________________________________
- City, State, Zip: ________________________________
- Phone Number: _________________________________
Special Instructions:
Please include any specific preferences or limitations regarding medical treatment:
____________________________________________________________________
____________________________________________________________________
Effective Date: This Medical Power of Attorney becomes effective upon my incapacity to make my own medical decisions, as determined by my attending physician.
Revocation: This document may be revoked by me at any time while I am still capable of making my own health care decisions.
Signature of Principal: __________________________________
Date: _____________________________________________
Witnesses:
- Signature: _______________________ Date: ___________
- Signature: _______________________ Date: ___________
Note: Witnesses must not be related to you or entitled to anything from your estate.
This document should be stored in a safe place, and copies should be given to your agent, your physician, and any other relevant individuals.