CARY ADULT MEDICINE

If you have recently executed any of the above documents or have changed these documents please complete this form If you need information on living wills or advanced directives visit http://www.carymed.com/healthpower2.pdf

Do you have a living will? If yes do we have a copy of the living will in the chart? Approximately what date was your living will executed? Does anyone else have a copy of this living will If yes what is name and relation of person that has copy? What is best contact information for that individual? Do you have a healthcare power of attorney If yes do we have copy of your healthcare power of attorney? Approximately what date was your healthcare power of attorney executed? Does any one else have a copy of your healthcare power of attorney? What is the best contact information for that individual? Who is your healthcare power of attorney? What is their relationship to you? Please provide us with contact information for that individual? Other information you would like to incluide