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OFFICE OF THE ARIZONA ATTORNEY GENERAL
Mark Brnovich

STATE OF ARIZONA
DURABLE HEALTH CARE POWER OF ATTORNEY
Instructions and Form
GENERAL INSTRUCTIONS: Use this Durable Health Care Power of Attorney form if you want to select a person to
make future health care decisions for you so that if you become too ill or cannot make those decisions for yourself the
person you choose and trust can make medical decisions for you. Talk to your family, friends, and others you trust about
your choices. Also, it is a good idea to talk with professionals such as your doctor, clergyperson and a lawyer before you
sign this form.
Be sure you understand the importance of this document. If you decide this is the form you want to use, complete the
form. Do not sign this form until your witness or a Notary Public is present to witness the signing. There are further
instructions for you about signing this form on page three.
1. Information about me (the Principal):
My Name:
My Address:

_

My Age:
My Date of