Maryland Advance Directive

Information you will need

• Principal Name
• Date of Birth
• Agent Name
• Agent Street Address
• Agent Home and Cell Phone Numbers
• Agent City, State, ZIP Code
• Back Up Agent Name
• Back Up Agent Street Address
• Back Up Agent City, State, ZIP Code
• Back Up Agent Home and Cell Phone Numbers
• Second Back Up Agent Name
• Second Back Up Agent Street Address
• Second Back Up Agent City, State, ZIP Code
• Second Back Up Agent Home and Cell Phone Numbers
• Consultant Name
• Consultant Phone Number
• Pregnancy Instructions
• Conditions and Limitations
• Effective Immediately
• Effective Upon Incapacitation
• Goals and Values
• Terminal Condition
• Vegetative State
• End Stage Condition

…and 14 more fields in the PDF.

Completed by the agent and the donor and the declarant.

The form includes a witness section.