This form can be used to:

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


This form is based on the “model” form set out in § 54.1-2984 of the Virginia Code. 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 allows you to grant your agent the power to agree to treatment on your behalf even when you are objecting that care (called the “Ulysses Clause”).



You can download a PDF of the Statutory Form by clicking here.

The Statutory Form