Vermont Medical Power of Attorney Form

The Vermont medical power of attorney form is a legal document designed to allow a Principal to clearly outline the health care decisions they would choose for themselves. The Principal would name and entrust their wishes to an Agent, to ensure that their wishes would be properly carried out. The document will direct many levels of the Principal’s health care choices. The document will also address after death choices.

The Principal may choose to consult with an attorney for assistance with this document. This form may be revoked any time at the discretion of the Principal.

How to Write

Step 1 – Introduction –

  • Download the document and carefully review all of the information provided

Step 2 – Principal’s Information – Enter the following:

  • Principal’s Name
  • Date of Birth in mm/dd/yyyy format
  • Date of execution of the document
  • Street Address
  • City
  • State
  • Zip Code

Step 3 – Appointment of Agent – Submit Agent’s Information as follows:

  • Agent’s name
  • Complete address
  • Home phone
  • Work phone
  • Cell phone
  • Agent’s email address
  • List co-agent’s on a separate sheet

Step 4 – Alternate (Successor) Agent – Enter:

  • Alternate Agent’s name
  • Complete address
  • Home phone
  • Work phone
  • Cell phone
  • Alternate’s email address
  • List others who may be contacted if needed

Step 5 – Primary Care Providers – Provide the following:

  • Primary Care Provider’s name(s)
  • Telephone number(s)
  • Physical addresses

Step 6 – Principal’s Initial Selections – Complete the following:

  • Principal’s full name
  • Date of Birth in mm/dd/yyyy format
  • Date of completion of the document

Names of those who should not be contacted – enter these names into the box provided

  • Click the selected bubble preceding the Principal’s choice as to when the Agent should begin working with the document – select from:
  • When the Principal cannot make their own decisions
  • Now
  • When a specific event occurs

Step 7 – Principal’s Overall Health Care Goals – Principal must click the applicable bubbles –

  • Prefers to have life sustained as long as possible
  • If the second bubble is selected click all applicable boxes that the Principal would prefer
  • Direct treatment only toward Principal’s comfort

Additional Goals, Wishes, Beliefs –

  • Type or print additional goals, wishes, beliefs into the box provided

People to notify in the event of a life threatening illness –

  • Type or print names and contact numbers

Selection of location in an end of life scenario – 

  • Select the preference of location by clicking the applicable bubble preceding the Principal’s selection

Spiritual Care Wishes – Enter:

  • Principal’s Faith/Religion
  • Place of work
  • Phone number
  • Address
  • Enter any items, music or readings to provide comfort

Step 8 – Treatment Limitation Preferences –

  • Make selections appropriate to the wishes of the Principal by clicking the bubble preceding each selection in 1 through 4 of this section
  • Enter any additional choices of limitations of treatment into the box provided

Step 9 – Organ and Tissue Donations –

  • The Principal may review the selections and click the applicable box
  • If there are specific selections, enter them onto the line next to the box, if selected

Step 10 – Burial and Disposition of Remains Post Death – Review the selections:

  • Click any applicable boxes
  • Provide name, address and telephone numbers of the person to be contacted

Specific Wishes –

  •  Make selection by clicking the preferred box and add any additional information in the lines provided

Step 11 – Final Arrangement Preferences –

  • Make any preferred final selections and state any additional instruction in the box provided

Step 12 – Witnesses Signatures –

  • Witnesses may not be related
  • Witnesses may not have interested in the Principal’s estate
  • Principal must read the statement and provide their signature and date the signature in mm/dd/yyyy format
  • AND
  • Witnesses must read and agree to the affirmation statement, then provide (respectively):
  • Witness’ Printed name
  • Signature
  • Date of signature
  • Address

Step 13 – Person Completing Document – Read the information and provide:

  • Name
  • Date of signature in mm/dd/yyyy format
  • Title/Position
  • Phone number
  • Physical address

Step 14 – Copies of Principals Document –

  • Provide information regarding all who hold a copy of this document