Enduring Power of Attorney & Medical Treatment Decision Maker Form

YOUR FULL LEGAL NAME INCLUDING ANY MIDDLE NAMES: *

PLEASE LIST ANY OTHER NAMES YOU ARE KNOWN BY OR MAY HOLD ASSETS UNDER:

YOUR DATE OF BIRTH (DD/MM/YYYY): *

YOUR PHONE NUMBER: *

YOUR EMAIL ADDRESS: *

YOUR OCCUPATION: *

YOUR CURRENT RESIDENTIAL ADDRESS: *

MARITAL STATUS

Which document(s) would you like us to prepare?

Enduring Power of Attorney (Financial & Personal Matters)
This document allows you to appoint someone you trust to make decisions about your finances, property, and lifestyle if you become unable to manage these yourself (or if you choose, to act for you immediately if required). They may help with tasks like paying bills, managing your bank accounts (including withdrawing money), buying or selling property for you or deciding where you live or receive care.
You decide when their authority begins and can include conditions or limitations. Your attorney must be over 18 and agree to the role - they will need to sign an acceptance statement so please discuss this with them before you appoint them. They should not be a former bankrupt or a paid carer and they should be practically available to act if needed. You can appoint more than one attorney, including substitute (alternative) attorneys, and specify how they are to act. For example, you may require that attorneys act jointly, meaning they must agree and sign together for any decisions to be valid. Alternatively, you can allow them to act severally, meaning either one can make decisions and sign documents independently. You may also allow them to act jointly and severally, giving them the flexibility to act together or alone as needed.

Appointment of Medical Treatment Decision Maker
This document allows you to appoint someone to make medical decisions on your behalf if you lose capacity. They can consent to or refuse treatment based on what they believe you would want.
You must trust the person you appoint and ensure they understand the responsibility. Your medical treatment decision maker must be over 18 and agree to the role - they will need to sign an acceptance statement so please discuss this with them before you appoint them. They cannot be a paid carer, and ideally should be someone accessible and capable of making difficult decisions under pressure. If you have more complex needs and specific instructions regarding the medical treatment you may or may not wish to consent to in the future, you will need to see your doctor to prepare an 'Advanced Care Directive'.

DOCUMENTS TO BE PREPAREDENDURING POWER OF ATTORNEY (FINANCIAL AND PERSONAL)MEDICAL TREATMENT DECISION MAKER APPOINTMENTPlease select documents you would like prepared

Please provide Name, Address, Phone Number, Email address and Date of Birth of your FIRST ATTORNEY

If you are appointing a second Attorney please provide Name, Address, Phone Number, Email address and Date of Birth of your ALTERNATE (SECOND) ATTORNEYOnly complete If you are appointing a second Attorney

If you are appointing a third Attorney please provide Name, Address, Phone Number, Email address and Date of Birth of your ALTERNATE (THIRD) ATTORNEYOnly complete If you are appointing a third Attorney

If you are appointing a fourth Attorney please provide Name, Address, Phone Number, Email address and Date of Birth of your ALTERNATE (FOURTH) ATTORNEYOnly complete If you are appointing a fourth Attorney

Please provide Name, Address, Phone Number, Email address and Date of Birth of your FIRST MEDICAL TREATMENT DECISION MAKER

If you are appointing a second Medical Treatment Decision Maker please provide Name, Address, Phone Number, Email address and Date of Birth of your SECOND MEDICAL TREATMENT DECISION MAKEROnly complete if you are appointing a second Medical Treatment Decision Maker

If you are appointing a third Medical Treatment Decision Maker Please provide Name, Address, Phone Number, Email address and Date of Birth of your THIRD MEDICAL TREATMENT DECISION MAKEROnly complete If you are appointing a third Medical Treatment Decision Maker

If you are appointing a fourth Medical Treatment Decision Maker Please provide Name, Address, Phone Number, Email address and Date of Birth of your FOURTH MEDICAL TREATMENT DECISION MAKEROnly complete If you are appointing a fourth Medical Treatment Decision Maker

How can your attorneys act (if more than one appointed)Jointly – they MUST act together and agree on all decisions jointlyJointly and Severally – each can act alone or togetherOther - please specifyIf more than one attorney is appointed, how should they act?

Please explain how your attorneys should act

When can your attorney(s) act?ONLY if I lose decision-making capacityONLY if I lose capacity AND a doctor provides a letter stating thisImmediately upon signingOther ConditionsWhen can your attorney(s) begin acting?

If “Other Conditions” is selected:

Have you already made a Will?YESNO

If you have made a Will before - location of your original Will

PLEASE PROVIDE ANY FURTHER INSTRUCTIONS, QUESTIONS OR COMMENTS REGARDING PREPARING YOUR POWER OF ATTORNEY DOCUMENTS

HOW DID YOU HEAR ABOUT CAMPUS LAWYERS? *I am a returning clientGoogleOther - please let us know how you heard about us?

HOW DID YOU HEAR ABOUT US? *