Forms > Temporary Medical Power of Attorney Form

Temporary Medical Power of Attorney Form

A temporary medical power of attorney form allows an agent to make medical decisions on your behalf for a temporary period only. You can appoint an agent or attorney to make medical decisions on your behalf should you be incapacitated and therefore unable to make the decisions yourself. Find here below a sample temporary medical power of attorney form.

Sample Temporary Medical Power of Attorney Form

I ______________________ being of sound body and mind and without any coercion do hereby give my authority and permission to __________________ to make medical decisions on my behalf for a temporary period starting from _________________ to _________________ in the event that I am incapacitated and therefore unable to make the medical decisions myself. I hereby state that I fully understand that by signing this form I give my consent to ______________ to make medical decisions for me for a specified temporary time period in the event that I am incapacitated.

Signature: _______________________ Date: _________________________

In witness of: ____________________ Signature: _____________________

Date: __________________________

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