This form can be used to:

  • Appoint an agent,
  • Show which powers you want to give your agent,
  • Write brief health care instructions,
  • Write instructions about end-of-life care, and
  • Write instructions about organ donation.

This form is based on the “model” form set out in Virginia law. This form does not give you as much guidance and flexibility as the Integrated Form or the VHHA Form in writing instructions about end-of-life care.

This form includes the special power in which you can give your health care agent the power to agree to treatment even when you are objecting to that care.

You can download a PDF here.

The Health Care Decisions Act Form