Iowa Medical Power of Attorney
This document allows you to appoint someone to make medical decisions on your behalf in case you are unable to do so. It is important to select someone you trust to carry out your wishes. This document is based on Iowa state laws.
Instructions
Complete the information below to create your Medical Power of Attorney document.
Principal Information
- Full Name: ________________
- Address: ________________
- City, State, Zip Code: ________________
- Date of Birth: ________________
Agent Information
- Agent's Full Name: ________________
- Address: ________________
- City, State, Zip Code: ________________
- Phone Number: ________________
Alternative Agent Information
- Alternative Agent's Full Name: ________________
- Address: ________________
- City, State, Zip Code: ________________
- Phone Number: ________________
Medical Decisions
You are granting your agent the authority to make decisions regarding your healthcare, including:
- Your treatment options.
- Medical procedures.
- End-of-life care.
- Access to medical records.
Signatures
This document must be signed by you and two witnesses. Both witnesses should not be related to you or be your attending physician.
- Signature of Principal: ________________
- Date: ________________
- Witness 1 Signature: ________________
- Date: ________________
- Witness 2 Signature: ________________
- Date: ________________
Notary Public (if required)
If desired, this document may be notarized.
Notary Signature: ___________________
Date: ___________________