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Special Power Of Attorney For Medical Authorization
I, ___________(1)___________, of __________(2)_________, hereby
appoint ______________(3)________________ of ___________(4)_______________, as my attorney
in fact to act in my capacity to do any and all of the following:
1. Make any and all decisions and authorize all procedures that
_____(5)____ may deem necessary regarding the medical treatment of my children,
_____(6)_____ and/or ______(7)______.
The rights, powers, and authority of my attorney in fact to exercise
any and all of the rights and powers herein granted shall commence and be in full force
and effect and shall remain in full force and effect until ___________(8)_______________
or unless specifically extended or rescinded earlier by either party.
Dated ___________(9)______________, 19_(10)_.
____________(11)______________
STATE OF _______(12)____________
COUNTY OF ______(13)____________
BEFORE ME, the undersigned authority, on this _(14)_ day of
_______(15)________, 19_(16)_, personally appeared ___________(17)___________ to me well
known to be the person described in and who signed the Foregoing, and acknowledged to me
that he executed the same freely and voluntarily for the uses and purposes therein
expressed.
WITNESS my hand and official seal the date aforesaid.
__________(18)_________________
NOTARY PUBLIC
My Commission Expires:__(19)___
NOTICE
The information in this document is designed to provide an outline that
you can follow when formulating business or personal plans. Due to the variances of many
local, city, county and state laws, we recommend that you seek professional legal
counseling before entering into any contract or agreement.
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