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1
I, ________________________________________________________________________(the principal),
residing at________________________________________, __________________ County, Massachusetts,
pursuant to Massachusetts General Laws Chapter 201D, appoint the following person to be my Health Care
Agent:
Name:
___________________________________
Phone #:
___________________________________
Address:
______________________________
City/State/Zip:
___________________________________
If my Health Care Agent named above is not available, I name as an alternate Health Care Agent:
Name:
___________________________________
Phone #:
___________________________________
Address:
______________________________
City/State/Zip:
___________________________________
I give my Health Care Agent authority to make all health care decisions on my behalf if I become incapable
of making such decisions for myself, including but not limited to decisions concerning initiation, continuing,
withdrawing or refusing any life-prolonging care, treatment, service or procedure, EXCEPT (here list the
limitations, IF ANY, you wish to place on your Agent’s authority):