Personal Directive Form

You may now prepare a Personal Directive appointing an agent to act on your behalf should you become mentally incompetent to make decisions about the following subjects.:
- (A) your medical care
- (B) where you will live
- (C) your social activities
- (D) educational pursuits
- (E) employment
- (F) legal and personal matters
A Personal Directive is your opportunity to deal in advance with the possibility of becoming mentally incompetent to deal with your own decisions relating to the subjects as outlined above.
Your Information:
Name*
First Last
Address*
Street Address City Province Postal Code
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
Phone Number: home*
Cell/Work
Email*
Agent:
NAME(S):*
ADDRESS:*
RELATIONSHIP TO YOU:*
Email*
Phone number*
ALTERNATE AGENT(S): (OPTIONAL)
NAME(S):
ADDRESS:
RELATIONSHIP TO YOU:
NAME(S):
ADDRESS:
RELATIONSHIP TO YOU:
Jointly or severally*

Would you like your agents to make all major decisions jointly or can major decisions be made by your agents individually on an as needs basis?
Would you want your life to be prolonged by artificial means when you are in a coma, or a persistent vegetative state and, in the opinion of your physician and other consultants, have no known hope of regaining awareness and higher mental functions, no matter what is done.*
- YES
- NO
Do you wish to be kept comfortable and free from pain, meaning that you may be given pain medication even though it may dull consciousness and indirectly shorten your life.*
- YES
- NO

Your Information: