Appoint a Health Care Proxy

    Oklahoma law does not authorize family members to make medical treatment decisions for a patient who cannot make their own decisions because of incapacity.  It is important for every adult to complete the form below to choose a representative to make medical decisions.  The form must be dated and signed and witnessed by to persons 18 years of age or older who are not related and will not inherit from the patient.  The witnesses should not be the persons appointed as proxies.

 

Appointment of Health Care Proxy

    If my attending physician and another physician determine that I amno longer able to make decisions regarding my healthcare, I direct my attending physician and other health providers, pursuant to the Oklahoma Advance Directive Act to follow the instructions of _________________________________________________________________________, whom I appoint as my primary health care proxy.  If my primary health care proxy isunable or unwilling to serve, I appoint _________________________________________________________________________ as my alternate health care proxy withthe same authority.  My primary health care proxy or alternate is authorized to make whatever health care decisions I could make if I were able regarding medical treatment, including both life-sustaining and non life-sustaining treatment and artificially administered nutrition and hydration.

 

Signed this ________day of ___________________, 20_____.

(Patient)___________________________________________

 

Witness Name (Print)___________________________________

Witness Signature______________________________________

Witness Phone________________________________________

 

Witness Name (Print)___________________________________

Witness Signature______________________________________

Witness Phone________________________________________