Vermont Medical Power of Attorney
This Medical Power of Attorney document is designed to comply with the laws of the State of Vermont. It grants authority to your chosen representative to make medical decisions on your behalf in the event you are unable to do so yourself. Please ensure all information provided is accurate and consult a legal professional if you have any questions.
Principal Information
Principal's Full Name: ___________________________________________
Principal's Date of Birth: ________________________________________
Principal's Address: _____________________________________________
Agent Information
Agent's Full Name: _______________________________________________
Agent's Relationship to Principal: ________________________________
Agent's Address: _________________________________________________
Agent's Phone Number: ____________________________________________
Alternate Agent Information (Optional)
If the first agent is unable or unwilling to serve, an alternate agent can act on the principal's behalf. Providing an alternate agent is optional.
Alternate Agent's Full Name: ______________________________________
Alternate Agent's Relationship to Principal: ______________________
Alternate Agent's Address: ________________________________________
Alternate Agent's Phone Number: __________________________________
Authority Granted to Agent
This document grants the agent the authority to make all medical decisions on behalf of the principal, including, but not limited to:
- Consent or refuse consent to any medical treatment.
- Access the principal's medical records.
- Make decisions about the principal's placement in a healthcare facility.
- Make decisions about palliative care and end-of-life treatment.
This authority is subject to any limitations specified in this document.
Limitations on Agent's Authority (Optional)
If there are any specific limitations on the agent's authority, describe them here: _____________________________________________________________
Duration of Power of Attorney
This Medical Power of Attorney will become effective immediately upon signing and will remain in effect:
- Until the principal revokes it in writing.
- If the principal becomes incapacitated, unless the principal has specified an expiration date or event.
Signatures
This document must be signed by the principal, the agent, and an adult witness not related to the principal. It does not require notarization in the State of Vermont.
Principal's Signature: _________________________________ Date: ____________
Agent's Signature: _____________________________________ Date: ____________
Alternate Agent's Signature (if applicable): ______________ Date: ____________
Witness's Signature: _____________________________________ Date: ____________
Statement of Witness
I, _______________________________ (print name), declare that the principal appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as agent or alternate agent in this document.
Witness's Address: ___________________________________________________
Witness's Phone Number: ______________________________________________