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Important
Note:
Forms are to be used as a guide only to assist you. No liability is assumed for errors in substance or form. It is your responsibility to revise the forms to meet current law
requirements and your particular situation. No liability is assumed for improper use of these forms.
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SPECIAL
POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION
I,
________________________, of _____________________, hereby appoint
________________________________
of ____________________________, 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 ___________ may deem
necessary
regarding the medical treatment of my children, ____________ and/or
______________.
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 ____________________________ or unless specifically extended or
rescinded
earlier by either party.
Dated
___________________________, 19____.
____________________________
STATE OF
_____________________
COUNTY OF
____________________
BEFORE ME, the
undersigned authority, on this ____ day of _________________,
19____,
personally appeared ________________________ 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.
_____________________________
NOTARY PUBLIC
My Commission
Expires:_______
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