Medical Power of Attorney

MEDICAL POWER OF ATTORNEY FOR COVID 19 OR VARIANTS
STATE OF ______________ §
§ KNOW ALL MEN BY THESE PRESENTS
COUNTY OF ____________ §
I, _______________, appoint
Name:
Addres
s:
Phone:
as my agent(s) to make any and all health care decisions for me, except to the extent I state
otherwise in this document. The agents listed above can work together or if needed in an attorney
client capacity. 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.
LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS

FOLLOWS:
This Power of Attorney specifically is to be used for the limited purpose of determining
treatment options associated with a Covid 19, variants or illnesses derived thereof
diagnosis or for the treatment of side effects from vaccines associated with Covid 19 or
its variants.
DESIGNATION OF ALTERNATE AGENT
If the person designated as my agent is unable or unwilling to make health care decisions
for me, I designate the following person to serve as my agent to make health care decisions for
me as authorized by this document:
Name:
Address:
Phone:
DURATION.
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.
This Covid19 related Medical Power of Attorney is in effect for one year from the date of
signature below.
DISCLOSURE STATEMENT.
THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL

DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE
IMPORTANT FACTS:
Specifically, you acknowledge that this document is intended to support your

decision as a sovereign individual and your rights as a patient as described in your
Advanced Directive for Covid 19. You acknowledge that all treatment options for Covid 19
have risks. You are making a conscience decision to forego the use of the ventilator and/or
Remdesivir and direct your Medical Power of Attorney to seek alternative treatment
options. You acknowledge that in seeking alternative treatment options there are still risks
associated and there is no guarantee that you will succumb to death or suffer from serious
bodily injury and only expect that your agents comply with your wishes and that they make
the best decision available at the time
Except to the extent you state otherwise, this document gives the person you name as
your agent the authority to make any and all health care decisions for you in accordance with
your wishes, including your religious and moral beliefs, when you are unable to make the
decisions yourself. Because "health care" means any treatment, service, or procedure to
maintain, diagnose, or treat your physical or mental condition, your agent has the power to make
a broad range of health care decisions for you. Your agent may consent, refuse to consent, or
withdraw consent to medical treatment and may make decisions about withdrawing or
withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental
health services, convulsive treatment, psychosurgery, or abortion. A physician must comply with
your agent's instructions or allow you to be transferred to another physician.
Your agent's authority is effective when your doctor certifies that you lack the
competence to make health care decisions.
Your agent is obligated to follow your instructions when making decisions on your
behalf. Unless you state otherwise, your agent has the same authority to make decisions about
your health care as you would have if you were able to make health care decisions for yourself.
It is important that you discuss this document with your physician or other health care
provider before you sign the document to ensure that you understand the nature and range of
decisions that may be made on your behalf. If you do not have a physician, you should talk with
someone else who is knowledgeable about these issues and can answer your questions. You do
not need a lawyer's assistance to complete this document, but if there is anything in this
document that you do not understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust. The person
must be 18 years of age or older or a person under 18 years of age who has had the disabilities of
minority removed. If you appoint your health or residential care provider (e.g., your physician or
an employee of a home health agency, hospital, nursing facility, or residential care facility, other
than a relative), that person has to choose between acting as your agent or as your health or
residential care provider; the law does not allow a person to serve as both at the same time.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS:
(1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED

BEFORE A NOTARY PUBLIC; OR
(2) YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT

WITNESSES.
THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:
(1) the person you have designated as your agent;
(2) a person related to you by blood or marriage;
(3) a person entitled to any part of your estate after your death under a will or codicil
executed by you or by operation of law;
(4) your attending physician;
(5) an employee of your attending physician;
(6) an employee of a health care facility in which you are a patient if the employee is
providing direct patient care to you or is an officer, director, partner, or business
office employee of the health care facility or of any parent organization of the
health care facility; or
(7) a person who, at the time this medical power of attorney is executed, has a claim
against any part of your estate after your death.
By signing below, I acknowledge that I have read and understand the information
contained in the above disclosure statement.
I sign my name to this medical power of attorney on the day of , 2021

at______________________.
_________________________
SUBSCRIBED AND SWORN TO BEFORE ME by the said ________________,

Principal, this _______________ day of ______________________________, 2021.
Notary Public, State of Texas
FORM PREPARED BY:

Kellye SoRelle, Attorney
Texas Bar No. 24053486
[email protected]

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MEDICAL POWER OF ATTORNEY FOR COVID 19 OR VARIANTS

LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS

DESIGNATION OF ALTERNATE AGENT

THIS MEDICAL POWER OF ATTORNEY IS AN IMPORTANT LEGAL

Specifically, you acknowledge that this document is intended to support your

THIS POWER OF ATTORNEY IS NOT VALID UNLESS:

(1) YOU SIGN IT AND HAVE YOUR SIGNATURE ACKNOWLEDGED

(2) YOU SIGN IT IN THE PRESENCE OF TWO COMPETENT ADULT

THE FOLLOWING PERSONS MAY NOT ACT AS ONE OF THE WITNESSES:

(1) the person you have designated as your agent;

(2) a person related to you by blood or marriage;

(4) your attending physician;

(5) an employee of your attending physician;

I sign my name to this medical power of attorney on the day of , 2021

SUBSCRIBED AND SWORN TO BEFORE ME by the said ________________,

Notary Public, State of Texas

FORM PREPARED BY:

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