• DPA pour formulaire en anglais

  • L'idéal serait que tu remplisses ce formulaire avec tes personnes de confiance, ainsi, elles pourront signer en même temps que toi

     

    Merci de remplir TOUTES les zones du formulaire ci-dessous

     

    Le document en anglais se finalisera automatiquement avec ces informations.

  •   1. Je,               . résidant à                    remplis ce document d'instructions médicales pour énoncer mes instructions en cas d'incapacité à m'exprimer.

     2. En tant que Témoin de Jéhovah, je demande expressément qu' AUCUNE TRANSFUSION de sang total, de globules rouges, de globules blancs, de plaquettes ou de plasma ne me soit administrée, même si les professionnels de santé estiment que cela est nécessaire pour préserver ma vie. (Actes 15:28, 29)
    Je refuse également de donner en avance, et de stocker mon sang en vue d’une transfusion ultérieure.

  • 5. I give no one authority to disregard or override my instructions set forth herein. Even if family members, relatives, or friends disagree with my decision, such disagreement does not diminish the strength or substance of my refusal of blood or other instructions. 6. This legal directive is an exercise of my right to accept or to refuse medical treatment in accord with my deeply held values and convictions. My rights to self-determination

  • and personal autonomy, and to freedom of conscience and religion, require all health-care providers to comply with this directive.

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  • STATEMENT OF WITNESSES: The person who signed this document did SO in my presence. He or she appears to be of sound mind and free from duress, fraud, or undue influence. I am 18 years of age or older and I am not related by blood, marriage, or adoption to the person who signed this document and I am not the emergency contact, alternate emergency contact, Attorney/Guardian for medical treatment (which term includes enduring power of attorney for medical treatment or enduring guardian under the relevant state legislation) or alternate Attorney/Guardian of the person making this Advance Health Care Directive.

  • IN CASE OF EMERGENCY

  • please contact my emergency contact:

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  • This person is my appointed Attorney/Guardian for medical treatment under the relevant state legislation.

  • Advance Health Care Directive (signed document inside)

  • This person is my appointed Attorney/Guardian for medical treatment or alternate Attorney/Guardian for medical treatment under the relevant state legislation. dpa-E Au 1/16Page 2 of 2


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