TEXAS MEDICAL POWER OF ATTORNEY DESIGNATION OF HEALTH CARE AGENT. I, ____________________________________________________________, appoint: (name) _______________________________________________________________________ (name of agent) _______________________________________________________________________ (address) _______________________________ _____________________________ (work telephone number) (home telephone number) as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This medical power of attorney takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician. DESIGNATION OF ALTERNATE AGENT. (You are not required to designate an alternate agent but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by law if your marriage is dissolved.)If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order: A. First Alternate Agent _______________________________________________________________________ (name of first alternate agent) _______________________________________________________________________ (home address) _______________________________ ___________________________ (work telephone number) (home telephone number) B. Second Alternate Agent _______________________________________________________________________ (name of second alternate agent) _______________________________________________________________________ (home address) _______________________________ ___________________________ (work telephone number) (home telephone number) >>>> 2 I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself. (IF APPLICABLE) This power of attorney ends on the following date: _________ ACKNOWLEDGMENT OF DISCLOSURE STATEMENT. I have been provided with a disclosure statement explaining the effect of this document. I have read and understood that information contained in the disclosure statement. I sign my name to this medical power of attorney on (date) the ____ day of ____________________ _______, at ________________________________. (day) (month) (year) (city)_________________________________________ (signature) STATEMENT OF FIRST WITNESS. I am not the person appointed as agent by this document. I am not related to the principal by blood or marriage. I would not be entitled to any portion of the principals estate on the principals death. I am not the attending physician of the principal or an employee of the attending physician. I have no claim against any portion of the principals estate on the principals death. Furthermore, if I am an employee of a health care facility in which the principal is a patient, I am not involved in providing direct patient care to the principal and am not an officer, director, partner or business office employee of the health care facility of any parent organization of the health care facility. Signature: ____________________________________________________________ Print Name: ____________________________________ Date: ________________ Address: ______________________________________________________________ SIGNATURE OF SECOND WITNESS Witness Signature: ____________________________________________________ Print Name: ____________________________________ Date: ________________ Address: ______________________________________________________________