HEALTH CARE PROXY
I,__________________________, residing______________________________________________
(name of principal) (street) (city)
Massachusetts, do hereby appoint___________________________________________________________________________
(name of Health Care Agent) (area code & telephone
residing at _______________________________________________as my Health Care Agent with the authority
(street) (city)
to make all health care decisions on my behalf in accordance with the provisions of Chapter 201D of the
General Laws of Massachusetts. If my said Health Care Agent is unavailable, unwilling, incompetent or
otherwise disqualified so to serve as my Health Care Agent to make a timely decision regarding medical
treatment for me should I become incapacitated, I do hereby appoint________________________________
(name of alternate agent)
_____________________________ residing at _________________________________________________
(area code & telephone) (street) (city)
as my Alternate Health Care Agent.
This authority becomes effective if my attending physician determines in writing that I lack the capacity to
make or to communicate health care decisions myself. My Health Care Agent is then to have the same
authority to make health care decisions as I would if I had the capacity to make them EXCEPT: (here list the
limitations, if any, you wish to place on your Health Care Agent's authority.)
________________________________________________________________________________________
________________________________________________________________________________________
I direct my Health Care Agent to make decisions based on my Health Care Agent's assessment of my
personal wishes, moral values and religious beliefs as stated below or as he/she otherwise knows: (here state
your personal wishes or moral religious beliefs.) An example of such moral and religious beliefs is the
following: I am a Roam Catholic. It is my wish that my Health Care Agent make health care decisions for
me which are consistent with the authentic teaching of the Catholic Church and based upon my profound
respect for life and my belief in eternal life.
________________________________________________________________________________________
________________________________________________________________________________________
It is my intention that my attending physicians, and the health care institution where I am a patient, provide
me with proper medical treatment and care including but not limited to:
1. Appropriate pain-alleviating medicine.
2. Nutrition and hydration when they are capable of sustaining life, as long as this is of sufficient
benefit to outweigh the burdens involved to me.
3. Standard comfort care appropriate for any patient suffering from illness, injury, or disease.
If my personal wishes are unknown, my Agent is to make decisions based on my Agent's assessment of
what is in my best interest. Photocopies of this Health Care Proxy shall have the same force and effect of
the original.
____________________________________________.(signature of principal).
We, the undersigned witnesses, each declare and affirm that we know the identity of the person who signed
this Health Care Proxy, that the person appears to be at least eighteen years of age , of sound mind and
under no constraint or undue influence. Neither of us is named the Health Care Agent in this document.
Both of us witnessed the signature by the person who signed this Health Care Proxy, or witnessed it
signed at the person's direction, in our presence of each other
this _____________________(day)of ______________,___________(year).
Witness One:__________________________ Witness Two:_____________________________
Name (print)__________________________ Name(print)_________________________
Street _______________________________ Street ______________________________
City/State_____________________________ City/State ___________________________
Telephone (____)______________________ Telephone (____)_____________________