The following is a medical power of attorney form, this form is only applicable in the state of Florida in the United States of America. This form is used when one cannot make medical decisions by themselves owing to reasons beyond the control. This form provided here is just a reference document and you may need to edit or modify the contents of this document so that they meet your requirements.
A medical power of attorney is invoked when the person who created this medical power of attorney referenced in this document as “principal” is considered incapable of making medical decisions on their own behalf. The competence of the principal is decided by a registered medical practitioner, who has to provide in writing that the principal is unable to take medical decisions on his/her own behalf.
The form is filled with the details of the “agent” who is assigned to make decisions on behalf of the principal. Also mentioned in the documents are the radius conditions under which the power of attorney can be executed, and also the conditions under which the execution of the power of attorney is not allowed. For this form to be a valid power of attorney from you will need to fill in all the details and then get it notarized by a notary public from the state of Florida.
Text Version of The Form
AFFIDAVIT OF AGENT FORM
STATE OF _______________
COUNTY OF ______________
Before me, the undersigned authority, personally appeared _________________ (agent) (“Affiant”), who swore or affirmed that:
1. Affiant is the agent named in the Power of Attorney executed by _________________ (“Principal”) on _______________ (date).
2. This Power of Attorney is currently exercisable by Affiant. The principal is domiciled in ________________ (insert state, territory, or foreign country).
3. To the best of the Affiant’s knowledge after diligent search and inquiry:
The Principal is not deceased;
Affiant’s authority has not been suspended by initiation of proceedings to determine incapacity or to appoint a guardian or guardian advocate; and
There has been no revocation, partial or complete termination of the Power of Attorney or of Affiant’s authority.
4. Affiant is acting within the scope of authority granted in the Power of Attorney.
5. Affiant agrees not to exercise any powers granted by the Power of Attorney if Affiant attains knowledge that it has been revoked, partially or completely terminated or suspended, or is no longer valid because of the death or adjudication of incapacity of the Principal.
Sworn to (or affirmed) and subscribed before me this the ____ day of ___________ (month), ________ (year), by _________________ (Affiant)
(Signature of Notary Public- State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced Identification ______________________________
(Type of Identification Produced)