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Page 1

(Page 1 of )

Fill in with your first name(s) and surname

Fill in with your home address

DD/MM/YYYY

Page 2

(Page 2 of )

Insert your personal requests here in relation to the types of medical intervention you would find unacceptable (for example, artificial resuscitation and/or an artificial feeding tube inserted through the stomach wall).
You can write in full sentences or bullet points.

Page 3

(Page 3 of )

Do you have a health and welfare attorney?

Health and welfare attorney

[x]

[x]

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