Vermont Medical Power of Attorney
This Medical Power of Attorney is created in accordance with the laws of the State of Vermont. This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so.
Principal Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Date of Birth: ________________________
Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Phone Number: ________________________
Alternate Agent Information:
- Name: _______________________________
- Address: _____________________________
- City, State, Zip: ______________________
- Phone Number: ________________________
Effective Date: This Medical Power of Attorney becomes effective when I am unable to make my own medical decisions.
Limitations: You may specify any limitations on the authority granted to your agent below:
___________________________________________________________________________
___________________________________________________________________________
Signature:
I, _______________________________, the undersigned, hereby appoint the above-named agent to act on my behalf regarding my medical decisions.
Signature: _______________________________
Date: _______________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to you and who are not your agent.
- Witness Name: _______________________________
- Witness Signature: __________________________
- Date: _____________________________________
- Witness Name: _______________________________
- Witness Signature: __________________________
- Date: _____________________________________
Notarization:
State of Vermont
County of _______________________________
On this ____ day of ____________, 20__, before me, a Notary Public, personally appeared __________________________, known to me to be the person who executed this Medical Power of Attorney.
Notary Public Signature: __________________________
My Commission Expires: __________________________