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Advance Directive Questionnaire
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Information About the Person Making (Signing) the Advance Directives
First Name
*
Middle Name
Last Name
*
Email address
*
Phone Number
*
May we text this number?
*
Yes
No
Street Address
*
City, State Zip
*
Information About the Surrogate(s)
A
surrogate decision maker
, also known as a health care proxy or as agents, is an advocate for incompetent patients.
Surrogate - First Name
*
Surrogate - Middle Name
Surrogate - Last Name
*
Surrogate - Street Address
*
Surrogate - Street City, State Zip
*
Surrogate - Phone Number
*
Want to add an alternate surrogate?
*
Yes
No
Surrogate 2 - First Name
*
Surrogate 2 - Middle Name
Surrogate 2 - Last Name
*
Would you like to add another alternate surrogate?
*
Yes
No
Surrogate 3 - First Name
*
Surrogate 3 - Middle Name
Surrogate 3 - Last Name
*
Would you like to add another alternate surrogate?
*
Yes
No
Surrogate 4 - First Name
*
Surrogate 4 - Middle Name
Surrogate 4 - Last Name
*
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