The patient’s right to decide…
ADVANCE DIRECTIVES
VOLUSIA MEDICAL CENTER
161 North Causeway Ste A, New Smyrna
Beach, FL 32169
575 North Clyde Morris Boulevard Ste B,
Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
ADVANCE DIRECTIVES
PURPOSE: To extend patients’ autonomy and allow them to specify their wishes in the event they
lose the capacity to make healthcare decisions in the future.
SURROGATE DECISION-MAKER
PURPOSE: If the patient’s condition does not fit those specified by the directive or in the absence of
an advance directive, the patient may specify in advance a surrogate decision-maker to make
healthcare deicisions when the patient does not have the capacity to do so
DURABLE POWER OF ATTORNEY
PURPOSE: As an alternative or in addition to a surrogate decision-maker, you may designate a
durable power of attorney to act on your behalf. It is similar to a health care surrogate, but the
person can be designated to perform a variety of additional activities, including financial, legal,
medical, etc.
ORGAN DONATION
“If a person chooses to donate, after death, his or her body for medical training and research the
donation will be coordinated by the Anatomical Board of the State of Florida. You, or your survivors,
must arrange with a local funeral home, and pay, for a preliminary embalming and transportation of
the body to the Anatomical Board located in Gainesville, Florida. After being used for medical
education or research, the body will ordinarily be cremated. The cremains will be returned to the
loved ones, if requested at the time of donation, or the Anatomical Board will spread the cremains
over the Gulf of Mexico. For further information contact the Anatomical Board of the State of
Florida at (800) 628-2594 or www.med.ufl.edu/anatbd.”
(from Florida Health: http://www.floridahealthfinder.gov)
LIVING WILL
Definitions for terms on the Living Will form:
“End-stage condition” means an irreversible condition that is caused by injury, disease, or illness
which has resulted in progressively severe and permanent deterioration, and which, to a reasonable
degree of medical probability, treatment of the condition would be ineffective.
“Persistent vegetative state” means a permanent and irreversible condition of unconsciousness in
which there is: The absence of voluntary action or cognitive behavior of any kind and an inability to
communicate or interact purposefully with the environment.
“Terminal condition” means a condition caused by injury, disease, or illness from which there is no
reasonable medical probability of recovery and which, without treatment, can be expected to cause
death.
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Extracted from: http://floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Terminology:
Advance Directive: instruction of your future health care decisions when you
can’t make them yourself.
Artificial Nutrition and Hydration: food and water given through a tube or
needle
Autopsy: examination on body to find cause of death
Comfort Care: to control pain and to keep a person comfortable
CPR (Cardiopulmonary Resuscitation): is emergency treatment when a
person stops breathing or heart stops beating. May include pushing on the
chest, putting a tube down the throat, etc.
Health Care Appointment: you choose someone to make medical decisions
for you when you cannot make them youselves; aka “Health Care Proxy” or
“Durable Power of Attorney for Healthcare.”
Life-Sustaining Treatment: Means of keeping a person alive, may include a
breathing machine, CPR, and artificial nutrition and hydration
Health Care: advance directive in which you state your wishes of treatment
when you become terminally ill or in a persistent vegetative state
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Health Care Directive
“Living Will”
I, ___________________, wish to express my choices for medical treatment. I want everyone who cares for me to
know what health care I want when I am unable to communicate my wishes myself. It is my desire that the choices I
have made in this directive be honored by my family, physicians and others who may be responsible for my care.
If I am diagnosed to be in a Terminal Condition or in a Permanently Unconscious Condition and unable to
express myself, these are my wishes:
(Write your initials before the item(s) below that you choose)
_____ Do everything without regard to pain, discomfort or other burdens.
As long as there is any chance of survival, I want what is medically necessary to be done. It does
not matter whether it causes pain, suffering, or other burdens.
Comments ______________________________________________________________________
_______________________________________________________________________________
_____Do everything only if probable benefits outweigh probable burdens.
I want my agent who is making decisions for me to consider the probable benefits of life
prolonging medical procedures (such as breathing machines, surgeries and feeding tubes) and to
weigh these against the probable burdens. I want my life prolonged only if my agent believes that
the pain, suffering, indignity and other burdens will bring me back to an acceptable quality of this
life. By acceptable quality of life, I mean living in a way that lets me do things that are important
and necessary to me. (Examples of those things could be: the ability to communicate, recognize
family or friends, feed myself, make decisions, take care of myself, etc.)
Comments ______________________________________________________________________
_______________________________________________________________________________
_____ Do not do any life-supportive treatment.
I want treatment limited to health care measures that are intended to keep me comfortable, relive
my pain, and maintain my dignity. If needed, I want to be given medication to alleviate pain or
discomfort even though such treatment may indirectly shorten my life.
I do not want any medical procedure to be provided or continue that would merely prolong my dying. (Initial one of
the following) _____ This includes feeding tubes.
_____ This does not include feeding tubes.
Comments ____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
You may also want to attach your personal statement or additional directions to this document.
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Uniform Donor Form
The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The
words and marks below indicate my desires:
I give:
(a) _____ any needed organs or parts
(b) _____ only the following organs or parts for the purpose of transplantation, therapy, medical
research, or education:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
(c) _____ my body for anatomical study if needed. Limitations or special wishes, if any:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Signed by the donor and the following witnesses in the presence of each other:
Donor’s Signature ___________________________________ Donor’s Date of Birth _____________
Date Signed ______________ City and State _____________________________________________
Witness _____________________________ Witness _____________________________
Street Address ________________________ Street Address ________________________
City _____________________ State ______ City _____________________ State ______
You can use this form to indicate your choice to be an organ donor. Or you can designate it on your
driver’s license or state identification card (at your nearest driver’s license office).
Extracted from: http://www.floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Designation of Health Care Surrogate
Name: ______________________________________________________
In the event that I have been determined to be incapacitated to provide informed consent for medical
treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care
decisions:
Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate
surrogate:
Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________
I fully understand that this designation will permit my designee to make health care decisions and to
provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of
health care; and to authorize my admission to or transfer from a health care facility.
Additional instructions (optional):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I further affirm that this designation is not being made as a condition of treatment or admission to a health
care facility. I will notify and send a copy of this document to the following persons other than my
surrogate, so they may know who my surrogate is.
Name ______________________________________________________
Name ______________________________________________________
Signed _____________________________________________________
Date _________________________
Witnesses 1. ________________________________________
2. ________________________________________
At least one witness must not be a husband or wife or a blood relative of the principal.
Extracted from: http://www.floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
ORGAN DONATION
CHOOSE ONE:
_____ Yes, I want to donate my organs, tissues or other parts of my body to benefit others. They may be used for
transplantation and/or medical research.
_____ Yes, I want to donate my organs, tissues or other parts of my body for transplantation only.
_____ Yes, I wish to donate only ________________________________________ for transplantation.
_____ No, I do not wish to donate any parts of my body for organ transplantation or medical research.
Dated this _________ day of ______________________ (month, year)
Signed _______________________________________________________________________________
_____________________________________________________________________________________
City, County and State of Residence
The declarer of this document has been personally known to me and I believe him/her to be of sound mind, and that
he/she signed this document freely and voluntarily. In addition, I am not the attending physician, an employee of the
attending physician or health facility in which the declarer is a patient, or any person who has a claim against any
portion of the estate of the declarer upon the declarer’s decease at the time of the execution of the directive.
Witness: _____________________________________________________________________________
Printed Name
Signature
Date
_____________________________________________________________________________________
Address
Witness: _____________________________________________________________________________
Printed Name
Signature
Date
_____________________________________________________________________________________
Address
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Designation of Health Care Surrogate
Name: ______________________________________________________
In the event that I have been determined to be incapacitated to provide informed consent for medical
treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care
decisions:
Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________
Phone: ______________
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate
surrogate:
Name ________________________________________________________
Street Address _________________________________________________
City ________________________ State __________ Phone _____________
I fully understand that this designation will permit my designee to make health care decisions and to
provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of
health care; and to authorize my admission to or transfer from a health care facility.
Additional instructions (optional):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I further affirm that this designation is not being made as a condition of treatment or admission to a health
care facility. I will notify and send a copy of this document to the following persons other than my
surrogate, so they may know who my surrogate is.
Name ______________________________________________________
Name ______________________________________________________
Signed _____________________________________________________
Date _________________________
Witnesses 1. ________________________________________
2. ________________________________________
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
At least one witness must not be a husband or wife or a blood relative of the principal.
Extracted from http://www.floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
DURABLE POWER OF ATTORNEY
FOR HEALTH CARE
(APPOINTMENT OF AN AGENT FOR HEALTH CARE DECISIONS)
I, _______________________________________________, as principal, appoint the person listed below
as my agent for health care decisions. This appointment applies when I cannot communicate myself
whether or not I am expected to recover.
If, in the future, I am unable to make my own health care decisions, this person will have the power to make
all health care decisions for me. This includes giving informed consent for accepting, withholding or
stopping my health care treatment, service or diagnostic procedure. I expect my agent to follow guidelines
in my Health Care Directive/Living Will, if I have one, and to choose what he or she thinks I would want if
I could make the decision myself.
If the first person listed below is unable to serve as my agent, I appoint the second person to serve.
Primary Agent:
_____________________________________________________________________________________
Name
Address
_____________________________________________________________________________________
City
State
ZIP
Phone
Alternate Agent:
_____________________________________________________________________________________
Name
Address
_____________________________________________________________________________________
City
State
ZIP
Phone
The existence of this Durable Power of Attorney for Health Care shall have no effect upon the validity of
any other Power of Attorney for other purposes that I have executed or may execute in the future.
I make the following additional instructions regarding my care:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
By signing this document, I indicate that I understand the purpose and effect of this Durable Power of
Attorney for Health Care.
Dated this ______ day of ____________, 20____.
Date
Month
Year
Signed: ______________________________________________________________________________
Residing at ___________________________________________________________________________
Address
___________________________________________________________________________
City
State
ZIP
Phone
This document requires a notary authentication.
State of _____________________________________
County of ___________________________________
On this day personally appeared before me, _________________________________________________
To me know to be the individual described in and who executed the within and foregoing instrument, and
acknowledged that he/she signed the same as his/her free and voluntary act and deed for the uses and
purposes therein mentioned.
Given under my hand and official seal this ___________day of _____________________, 20_________.
______________________________________________________
Notary’s signature
Notary Public in and for the State of _________________________
Residing in _____________________________________________
My appointment expires ___________________________________
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Life Attitude Profile Of
______________________________________________
General attitude toward life:
What is it that gives meaning to your life?
What religious traditions or spiritual practices are important to you?
What limitations to your health would most compromise your reason for living?
What, if anything, frightens you most about becoming seriously ill or dying?
Name some of your future goals.
General attitude toward illness, dying and death
What will be important to you when you are dying (e.g., physical comfort, no pain, family present,
spiritual needs addressed)?
Where would you prefer to die?
If your family cannot care for you at home and you do not meet criteria for acute hospitalization, do you
have a preference for where you would like your care to be provided? (e.g., Adult Foster Home, Skilled
Nursing Facility). Do you have a specific facility in mind?
What is your attitude toward death?
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
How do you feel about the use of certain life supportive treatments (e.g., CPR, respirator, artificial
nutrition/hydration, surgery, pain relief) in face of:
Terminal Illness?
Permanent coma?
Irreversible chronic illness (e.g., Alzheimer’s disease, permanent kidney dialysis)?
Would you always like to know the truth about your condition? (Comment or explain)
In which ways would you like to participate or share in making decision about your health?
Do you have additional comments, instructions, limitations regarding organ donation?
Other comments about your attitude toward illness, dying and death?
Legal and Financial Obligations
Do you have a Durable Power of Attorney for Health Care? If so, give name, address, and phone
number of the individual empowered by this document to make health care decisions for you.
Do you have a person designated to handle your finances if you become incapacitated? If so, who?
Additional Comments:
Wishes Regarding Your Funeral
Have you made funeral arrangements? If so, with whom?
Do you have any comments or directions concerning your funeral and burial or cremation?
How would you like your obituary (announcement of death) to read? (Attach a draft, if you choose)
Signature ________________________________________________ Date _____________________
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Life Values Worksheet of _______________________________________________________
Your Name
Read each question below and circle the appropriate response. This sheet may be attached to your
Living Will.
How important is it for you
Very
Some
Not at all
to allow nature to take its
course?
How important is living as
Very
Some
Not at all
long as possible even if
quality of life suffers?
How important are your
Very
Some
Not at all
spiritual beliefs and
practices?
How important is remaining
Very
Some
Not at all
independent?
How important is
Very
Some
Not at all
considering the burden your
care might be to others?
How important is being free
Very
Some
Not at all
of physical limitations?
How important is it to be
Very
Some
Not at all
mentally alert?
How important is being able
Very
Some
Not at all
to relate to others?
How important is being as
Very
Some
Not at all
free from pain as possible?
How important is having
Very
Some
Not at all
time with family and friends
before dying? (for yourself
or others)
How important is it for you
Very
Some
Not at all
not to prolong your dying?
How important is respecting
Very
Some
Not at all
the sacredness and dignity of
your life no matter the
quality of your life?
How important is leaving
Very
Some
Not at all
money to family, charity,
etc?
How important is avoiding
Very
Some
Not at all
expensive care especially if
quality of life cannot be
maintained?
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
How important is being able
to die at home if possible?
Very
Some
Not at all
Personal Statement of__________________________________________________________
Name
Questions for reflection and discussion:
1. What kind of medical condition, if any, would make life hard enough that you would find attempts to
prolong it undesirable? (check those that apply)
[ ] None
[ ] Intolerable pain
[ ] Permanent dependence on others
[ ] Inability to communicate
[ ] Inability to feed myself
[ ] Inability to make decisions
[ ] Inability to recognize family or friends
[ ] Other conditions you would regard as undesirable (list them below)
_________________________________________________________________________________
_________________________________________________________________________________
2. Which treatments would you want in a terminal condition or permanent unconscious condition? (Check
those that apply)
[ ] Treatments that offer improved function such as various therapies (list below)
_______________________________________________________________________________
[ ] Use of antibiotics
[ ] Comfort treatment including appropriate pain management, even if it may shorten your life
[ ] Artificial nutrition and hydration: giving nutrition or fluid through a tube
[ ] Other __________________________________________________________________________
3. In a terminal or permanent unconscious condition, what treatments would you consider burdensome or
treatments you would not want? (Check those that apply)
[ ] Cardiopulmonary Resuscitation: performing CPR to start your heart or breathing if either stops
(use of drugs and electric shock to start your heart, inserting a tube into throat to assist breathing)
[ ] Mechanical breathing: breathing by machine (respirator or ventilator)
[ ] Kidney Dialysis: cleaning the blood by machine or fluid passed through the belly
[ ] Artificial Nutrition and Hydration: giving food and water through a tube in the veins, nose, or
stomach
[ ] Invasive surgery
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
[ ] Blood transfusion
[ ] Chemotherapy (cancer treatment)
[ ] Other __________________________________________________________________________
Other additional comments: (Include below or on the back of the page anything else you think is
necessary to clarify your personal values concerning limits of life and goals of medical intervention.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature: ______________________________________________ Date _________________________
(This document may be attached to your Living Will)
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
CODE STATUS
In case of a cardiopulmonary arrest, code status specifies in advance what specific life-saving
measures will be attempted. Code Status categories helps physicians, nurses and other caregivers
make thoughtful decisions in advance, to balance the wishes to “do everything possible” with the
realities of a medical situation in which further attempts at resuscitation can only prolong suffering
without a chance of recovery. The Code Status ideally should follow the plan of care.
Please choose one of the following categories of resuscitative you would like to have attempted if
you were in a cardiopulmonary arrest and cannot communicate to us what you would prefer to be
done at that time. That is, to what extension do you want resuscitative measures to be taken?
 Category I: “Full Code.” All resuscitative measures performed, including chest compressions,
intubation, electrical cardioversion, medications, volume expanders, blood products, oxygen, etc.
 Category IIA: “Chemical Code.” NO chest compressions and NO intubations. However,
casopressors, antiarrhythmic drugs, electrical cardioversion, noninvasive mechanical ventilation, plus
IV antibiotics, oxygen, blood products and volume expanders are permitted
 Category IIB: NO intubation, NO chest compressions, NO antiarrhythmic drugs, NO
vasopressors and NO electrical cardioversion. However, IV antibiotics, blood products, volume
exapanders and oxygen are permitted.
 Category III: “Comfort Support.” NO resuscitative measures at all. Perform palliative measures
to increase patient comfort and dignity.

Note: You may change your code status at any time you wish.
Print Name
Signature
Date
Witness Print Name
Witness Signature
Date
Physician Print Name
Physician Signature
Date
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Living Will
Declaration made this _____ day of ________________, 2____, I, ____________________________,
willfully and voluntarily make known my desire that my dying not be artificially prolonged under the
circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically
incapacitated and
_____(initial) I have a terminal condition,
or _____(initial) I have an end-stage condition,
or _____(initial) I am in a persistent vegetative state,
and if my attending or treating physician and another consulting physician have determined that there is
no reasonable medical probability of my recovery from such condition, I direct that life-prolonging
procedures be withheld or withdrawn when the application of such procedures would serve only to
prolong artificially the process of dying, and that I be permitted to die naturally with only the
administration of medication or the performance of any medical procedure deemed necessary to provide
me with comfort care or to alleviate pain.
I do ___, I do not ___ desire that nutrition and hydration (food and water) be withheld or withdrawn when
the application of such procedures would serve only to prolong artificially the process of dying.
It is my intention that this declaration be honored by my family and physician as the final expression of
my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event I have been determined to be unable to provide express and informed consent regarding the
withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my
surrogate to carry out the provisions of this declaration:
Name ________________________________________________________
Street Address _________________________________________________
City _______________________ State _____________ Phone ___________
I understand the full import of this declaration, and I am emotionally and mentally competent to make this
declaration.
Additional Instructions (optional): ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(Signed) ___________________________________________________
Witness _____________________________
Street Address ________________________
City _____________________ State _______
Phone _________________
Witness _____________________________
Street Address ________________________
City _____________________ State ______
Phone ________________
At least one witness must not be a husband or wife or a blood relative of the principal.
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
Extracted from: http://www.floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
The card below may be used as a convenient method to inform others of your health care advance
directives. Complete the card and cut it out. Place in your wallet or purse. You can also make copies
and place another one on your refrigerator, in your car glove compartment, or other easy to find place.
Health Care Advance Directives
I, ___________________________________
have created the following Advance Directives:
Living Will
Health Care Surrogate Designation
Anatomical Donation
 Other (specify) _____________________
----------------------- FOLD --------------------------Contact:
Name
_____________________________
Address _____________________________
_____________________________
_____________________________
Phone _____________________________
Signature ____________________ Date _____
Extracted from http://www.floridahealthfinder.gov
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145
161 North Causeway Ste A, New Smyrna Beach, FL 32169
575 North Clyde Morris Boulevard Ste B, Daytona Beach, FL 32114
905 North Stone Street, Deland Fl 32720
PH: 386-424-1584, Fax: 888-900-7145