We are here to help our clients at this critical time, that’s why we are offering to complete a complimentary Healthcare Power of Attorney and/or Living Will for anyone in need. Please complete the short contact form below, and someone from our office will be in touch with you. CLICK HERE to learn more about how Butcher Elder Law is responding to the COVID-19 pandemic in Northeast Ohio.

Healthcare Power of Attorney Living Will

Please answer the questions on this form to help us prepare your Healthcare Power of Attorney and Living Will. All information you provide will be kept in strict confidence.
  • We encourage our clients first to choose agents who will follow their wishes even if their wishes do not align with the agent’s philosophy or wishes for the principal, and, next, to discuss their wishes with their agents beyond just terminal illness and permanent unconsciousness so that the agents know how their principals feel about certain healthcare measure as the principals grow older and face the need for other interventions. If you could not make your own healthcare decisions, even if just temporarily, who would you trust to make those decisions for you? Please provide their full legal name:
  • Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
  • If the person you designate predeceased you or was otherwise unable to act in the capacity as your healthcare agent, who would be the backup? Please provide their full legal name below.
  • Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
  • List the name of your second alternative healthcare agent (optional):
  • Please list the full address and phone number for your Primary Healthcare Agent, the person you designated above.
  • Are the agents the same as noted above for healthcare?
  • Please list the full legal name of your Guardian below:
  • Please list the full address and phone number for your Guardian, the person you designated above.
    If yes, you must also complete Donor Registry Enrollment. You would have completed this if you are designated as an organ donor on your drivers license.