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my agent to make decisions for me: ____ when I am no longer able to make health care decisions for myself; ____ when the following conditions or events occur (please specify) ; ____ immediately upon signing, allowing my agent to act for me now. as my Health Care Agent to make I APPOINT any and all health care decisions for me. This shall take effect in the event I become unable to make my own health care decisions or as otherwise indicated in this document. ADDRESS TELEPHONE (DAY) (EVENING).

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