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Oregon Advance Directive Form

An Oregon advance directive is a form that allows someone to select someone else to act on their behalf when making medical decisions. The form can be used in the event that the principal becomes unable to make decisions on their own due to mental incapacitation or other illness. It also includes space to outline preferences, including end-of-life treatments.

Signing Requirements (ORS 127.515(2)(b)) – Two (2) witnesses or a notary public.

Statutory Form

1. ABOUT ME.
Name: [NAME]
Date of Birth: [DAY] day of [MONTH], [YEAR]
Telephone numbers: (Home) [PHONE NUMBER] (Work) [PHONE NUMBER] (Cell) [PHONE NUMBER]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
E-mail: [EMAIL]

2. MY HEALTH CARE REPRESENTATIVE.
I choose the following person as my health care representative to make health care decisions for me if I can’t speak for myself.
Name: [NAME]
Relationship: [RELATIONSHIP]
Telephone numbers: (Home) [PHONE NUMBER] (Work) [PHONE NUMBER] (Cell) [PHONE NUMBER]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
E-mail: [EMAIL]
I choose the following people to be my alternate health care representatives if my first choice is not available to make health care decisions for me or if I cancel the first health care representative’s appointment.
First alternate health care representative:
Name: [NAME]
Relationship: [RELATIONSHIP]
Telephone numbers: (Home) [PHONE NUMBER] (Work) [PHONE NUMBER] (Cell) [PHONE NUMBER]
Address: [ADDRESS, CITY, STATE, ZIP CODE]
E-mail: [EMAIL]

3. MY SIGNATURE.
My signature: ____________________________________
Date: [DAY] day of [MONTH], 20[XX]

4. WITNESS.
WITNESS DECLARATION:
The person completing this form is personally known to me or has provided proof of identity, has signed or acknowledged the person’s signature on the document in my presence and appears to be not under duress and to understand the purpose and effect of this form. In addition, I am not the person’s health care representative or alternate health care representative, and I am not the person’s attending health care provider.
Witness Name (print): ____________________________
Signature: ____________________________________
Date: [DAY] day of [MONTH], 20[XX]
Witness Name (print): ____________________________
Signature: ____________________________________
Date: [DAY] day of [MONTH], 20[XX]

5. ACCEPTANCE BY MY HEALTH CARE REPRESENTATIVE.
I accept this appointment and agree to serve as health care representative.
Health care representative:
Printed name: __________________________________
Signature or other verification of acceptance: _____________
Date: [DAY] day of [MONTH], 20[XX]