d
Follow us

Health Care Power of Attorney Questionnaire

Please complete this form to provide the attorney information about you and the individual you trust to make health care decisions for you if you are unable or do not want to make them yourself. These decisions should be based on your values and wishes.

The agent must be 18 years old, know you well and be comfortable talking with and questioning your physicians or health care providers. A parent can be an agent.

When your power of attorney is drafted, an attorney will email you to schedule a time to review the document with you via Zoom. After the Zoom call, you are responsible for mailing the power to our office to be executed.

The $175 payment is due before you pick up or authorize us to mail the original document to you. Credit card payments are accepted at “Submit a payment” on the firm’s home page at wochnerlawfirm.com

  • Please Write Your Full Legal Name that appears on other documentation (i.e. Birth Certificate or Driver's License)
  • Please write your full home address, including zip code and city
  • Please write your primary contact number
  • Please write your primary email address
  • Agent #1

    This section contains information for your Primary Health Care Agent (the person that would make your medical decisions for you if you cannot)
  • Please put the full legal name of the person you would choose as Agent #1
  • Please write Agent #1's full address, including city and zip code
  • Please select the relationship type you have with Agent #1
  • Please write Agent #1's main contact number
  • Agent #2

    This section contains information for your Back Up Health Care Agent (the person that would make your medical decisions for you if you and Agent #1 cannot)
  • Please put the full legal name of the person you would choose as Agent #2
  • Please write Agent #2's full address, including city and zip code
  • Please select the relationship type you have with your Agent #2
  • Please write Agent #2's main contact number