Essential Elements of a Health Care Proxy

  • Name of adult who creates the proxy (the principal).
  • Name of agent.
  • Statement that principal intends agent to make health care decisions for him or her.
  • Principal's signature and date of signature.
  • Signature of two witnesses, date, and statement by witnesses that the principal appeared to execute the proxy willingly. Neither the agent nor alternate agent can serve as witnesses.

The proxy must be signed with the witnesses present. At the patient's request, an adult can sign the proxy for the patient if the patient is unable to sign.