Healthcare Proxy Designation Form

iLEAD LAW GROUP

艾利德律师事务所

(718) 939-9000 [email protected]

Manhattan: 99 Park Ave, Ste 830, New York, NY 10016 | Queens: 136-20 38th Ave, Ste 9J, Flushing, NY 11354 | NJ: 560 Sylvan Ave, Ste 3160, Englewood Cliffs, NJ 07632

Please complete all applicable sections. This information will be used to prepare your Healthcare Proxy document.

Important: A Healthcare Proxy allows you to appoint a trusted person to make medical decisions on your behalf if you become unable to do so. This form gathers your preferences and agent information for your attorney to draft the legal document.

I. Patient Information

Full Legal Name:

Date of Birth:

Address:

City:

State:

ZIP:

Phone:

II. Healthcare Agent (Primary)

Full Legal Name:

Relationship:

Address:

City:

State:

ZIP:

Phone:

Email:

III. Alternate Healthcare Agent

This person will serve as your healthcare agent if the primary agent is unable or unwilling to act.

Full Legal Name:

Relationship:

Address:

City:

State:

ZIP:

Phone:

Email:

IV. Medical Preferences

Please indicate your preferences for the following medical situations. Your healthcare agent will use these as guidance when making decisions on your behalf.

A. Life-Sustaining Treatment

If I am in a terminal condition or persistent vegetative state, my preference is:

Aggressive treatment — Use all available medical measures to prolong my life

Comfort care only — Focus on pain management and comfort, no life-prolonging measures

Case-by-case — Allow my healthcare agent to decide based on the specific circumstances

B. Artificial Nutrition & Hydration

If I am unable to eat or drink on my own:

I want artificial nutrition and hydration (feeding tube, IV fluids)

I do not want artificial nutrition and hydration

I want my healthcare agent to decide based on the circumstances

C. CPR (Cardiopulmonary Resuscitation) Preferences

If my heart stops beating:

I want CPR to be attempted

I do not want CPR (DNR — Do Not Resuscitate)

I want my healthcare agent to decide based on the circumstances

D. Organ Donation Wishes

I wish to donate any needed organs and tissues

I wish to donate only the following organs/tissues: ___________________________

I do not wish to donate any organs or tissues

I want my healthcare agent to decide

V. Religious or Cultural Considerations

Please describe any religious, spiritual, or cultural beliefs that should guide medical decisions made on your behalf:

VI. Other Medical Instructions

Please provide any additional instructions or wishes regarding your medical care:

VII. Emergency Contacts

Full Name	Relationship	Phone Number

I certify that the information and preferences provided above are true and accurate to the best of my knowledge. I understand this form is used for information-gathering purposes only and does not constitute an executed Healthcare Proxy.

Signature (Patient)

Printed Name

Date

CONFIDENTIALITY NOTICE: This form contains privileged and confidential medical and legal information intended solely for the use of iLEAD LAW GROUP. Completion of this form does not create an attorney-client relationship. This form is for informational purposes only and does not constitute legal or medical advice. This form is NOT a Healthcare Proxy document. A formal Healthcare Proxy must be prepared, signed, and witnessed in accordance with applicable state law. Please bring this completed form to your consultation appointment.