North Carolina Advance Directive

Information you will need

• Agent Name
• Agent Street Address
• Agent Work Telephone Number
• Agent Cell Phone Number
• Successor Agent (2) Name
• Successor Agent (2) Street Address
• Agent City, State, ZIP Code
• Successor Agent (1) City, State, ZIP Code
• Agent Home Telephone Number
• Successor Agent (1) Work Telephone Number
• Successor Agent (1) Home Telephone Number
• Successor Agent (1) Cell Phone Number
• Successor Agent (2) Work Telephone Number
• Successor Agent (2) Home Telephone Number
• Successor Agent (2) Cell Phone Number
• Primary Physician
• Secondary Physician
• Nutrition
• Nutrition Special Provisions
• Hydration
• Hydration Special Provisions
• Limitations Concerning Health Care Decisions
• Health Care Decision Limitations
• Limitations Concerning Mental Health Decisions

…and 41 more fields in the PDF.

Completed by the agent and the provider and the principal.

The form includes 1 signature line, a notary acknowledgment, a witness section.