bloodless.orgDurable Power of Attorney
Blood-Related Medical Decisions
I, [Your Name], born [Date of Birth], residing at [Your Address], being of sound mind, hereby declare:
1. Appointment of Healthcare Agent
I appoint [Agent Name] ([Relationship]) (phone: [Phone]) as my healthcare agent for all decisions relating to blood-based medical treatments.
If my agent is unable to serve, I appoint [Alternate Agent Name] (phone: [Phone]) as successor.
2. Blood-Related Directives
I hereby direct that the following blood products and procedures be handled as specified:
Whole blood transfusions UNDECIDED
Packed red blood cells UNDECIDED
Plasma UNDECIDED
Platelets UNDECIDED
Albumin UNDECIDED
Immunoglobulins UNDECIDED
Clotting factors UNDECIDED
Cell salvage UNDECIDED
Hemodilution UNDECIDED
Heart-lung bypass UNDECIDED
Executed in [State], [Country].
Signature / date
Witness 1
Witness 2 / Notary
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