1025 Alameda De Las Pulgas #426

Belmont, CA, 94002

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Estate Planning | Wills | Trusts | Probate

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spouse health care AGENT form

Nominate Agents and Alternate Agents over your Health Care decisions in the case you are incapacitated or unavailable.

Spouse Name

First Name

Last Name

1. Health Care Agent

Typically your spouse

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

2. Second Health Care Agent

First Name

Last Name

Relationship

Mother, Brother-in-Law, Aunt, Family Friend

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

3. Third Health Care Agent

First Name

Last Name

Relationship

Mother, Brother-in-Law, Aunt, Family Friend

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

4. Additional Spouse Health Care Agent(s)

Include Name(s), Relationship(s), Address(es), Phone Number(s)

Notes & Questions for Attorney: