David Thomas

Solicitor, Conveyancer & Notary

3, Sussex Terrace, Hawthorn, South Australia 5062
Telephone: (+ 61 8) 8172 1222
Facsimile: (+ 61 8) 8127 9553
Contact


INSTRUCTIONS FOR MEDICAL POWER OF ATTORNEY
(only for residents of South Australia)


You can use this form to give me instructions for the preparation of a South Australian Medical Power of Attorney.

This power of attorney provides for the appointment of a "medical agent" who has the power to make decisions about the grantor's medical treatment if the grantor is unable to do so for himself. It "endures" and remains effective when the grantor has lost his legal capacity, i.e., soundness of mind, memory and understanding. This enables relatives and treating doctors to have a clear understanding of the grantor's wishes.

This form can be used to give me instructions for a single Power of Attorney or for "mutual" or "mirror image" Powers of Attorney, i.e., where spouses appoint each other (with or without additional persons) as their medical agents. It is important to understand that only one medical agent at a time can act. You may appoint more than one medical agent, but the appointments must be in order of priority.

If I need any more information, I will contact you. Please provide as many contact details as you can.

Your e-mail address
This field is mandatory, otherwise submission of the form will fail
Your name
This field is mandatory, otherwise submission of the form will fail
YOU
(the person giving the instructions)
Full Name(s) (including surname or family name in BLOCKS)
Residential Address
Contact Address
Contact Telephone
(day and evening)
Contact Fax
Contact Email
Preferred means
INSTRUCTIONS
These instructions are for:
If for a relative, state your relationship to the grantor
If for a relative or friend, confirm that you are authorised to provide these instructions: Yes, I am authorised by the grantor(s)
The authority is in writing
The authority is verbal
Date of the authority:
GRANTOR
(the person granting the medical power of attorney)
Full Name(s) (including surname or family name in BLOCKS)
Full Address
Occupation(s) or description(s)
MEDICAL AGENT 1
(the first person whom you wish to appoint as your medical agent)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
MEDICAL AGENT 2
(the second person [if any] whom you wish to appoint as your medical agent)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
MEDICAL AGENT 3
(the third person [if any] whom you wish to appoint as your medical agent)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
CONDITIONS AND DIRECTIONS
You can impose certain conditions on, and give certain directions as to, the exercise of the medical agent's powers. These are some conditions or directions you may wish to consider. If you wish to impose any of these conditions, or give any of these directions, please tick the relevant box. Refusal of artificial life-sustaining measures when you are in the terminal phase of a terminal illness or in a persistent vegetative state
Refusal of certain drugs or medications - please specify:
Refusal of certain surgical procedures - please specify:
Refusal of certain non-surgical procedures, e.g., blood transfusions - please specify:
Other - please specify:
CUSTODY
Where do you want the original Medical Power of Attorney to be held?
If "Other", please specify:
EXECUTIONThe Grantor and the Medical Agent(s) must sign the Medical Power of Attorney in the presence of a Commissioner for Taking Affidavits in the Supreme Court of South Australia (usually a solicitor); a Justice of The Peace for South Australia; a proclaimed manager; a proclaimed member of the police force; a member of the clergy; or a registered pharmacist.
FEES Single Power of Attorney: $121-00 (including GST)

Two mutual Powers of Attorney: $198-00 (including GST)

Please send your payment as soon as you have received confirmation from me that I have accepted your instructions. Upon receipt of your payment, I will send the document(s) to the Grantor with instructions for execution.


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THANK YOU FOR YOUR INSTRUCTIONS!

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