VA SamariCare - Advance Directives

Patient First Name *

Patient Last Name *

Date of Birth *

Patient or Family Best Email Address

Date-Time

Patient Signature — type your full legal name to sign *

Primary Agent's First Name *

Primary Agent's Last Name *

Primary Agent's Phone (Home)

Primary Agent's Phone (Cell)

Primary Agent's Phone (Work)

Primary Agent's Email

Primary Agent's Home Address

Primary Agent's Signature — type full legal name

Back-up Agent's First Name *

Back-up Agent's Last Name *

Back-up Agent's Phone (Home)

Back-up Agent's Phone (Cell)

Back-up Agent's Phone (Work)

Back-up Agent's Email

Back-up Agent's Address

Back-up Agent's Signature — type full legal name

Nurse First Name *

Nurse Last Name *

Nurse Signature — type full legal name

I confirm the above signatures are authentic and electronically executed *