I, ____________________________, of ________, this ________ day of ________, ________, being of sound mind, willfully and voluntarily appoint ______________ of ______________ as my agent and attorney-in-fact, without substitution, with lawful authority to execute a directive on my behalf under Section 75-2-1105, governing the care and treatment to be administered to or withheld from me at any time after I incur an injury, disease, or illness which renders me unable to give current directions to attending physicians and other providers of medical services.

I have carefully selected my above-named agent with confidence in the belief that this person's familiarity with my desires, beliefs, and attitudes will result in directions to attending physicians and providers of medical services which would probably be the same as I would give if able to do so.

This power of attorney shall be and remain in effect from the time my attending physician certifies that I have incurred a physical or mental condition rendering me unable to give current directions to attending physicians and other providers of medical services as to my care and treatment.

________________________________________
Signature of Principal

State of __________ : ss.

County of ________

On the ________ day of ________, ________, personally appeared before me ____________________, who duly acknowledged to me that he has read and fully understands the foregoing power of attorney, executed the same of his own volition and for the purposes set forth, and that he was acting under no constraint or undue influence whatsoever.

____________________________________
Notary Public

My commission expires:____________________________________

Residing at: _____________________________________________

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