Virginia Advance Directive

Information you will need

• Principal Name
• Principal DOB
• Agent Name
• Agent Home Phone Number
• Agent Cell Phone Number
• Agent Work Phone Number
• Agent Email
• Agent Address
• Back up Agent Name
• Back up Agent Home Phone Number
• Back up Agent Cell Phone Number
• Back up Agent Work Phone Number
• Back up Agent Email
• Back up Agent Address
• Power 5 Option
• Health Care Consent Initials
• Mental Facility Consent Initials
• Mental Facility Consent Checkbox
• Health Care Consent Checkbox
• Health Care Objection
• Licensed Professional Signing Date
• Licensed Professional Name/Address
• Important Health Care Conditions
• Symptoms

…and 39 more fields in the PDF.

Completed by the agent and the provider and the donor.

The form includes 1 signature line, a witness section.