A Health Care Declaration is used to authorize someone to make medical decisions for you in
the event that you are not able to communicate with your medical provider. In the absence of
such a document, you may need to have a conservator appointed by the court to make such
decisions for you in the event that you cannot communicate with your medical provider.

Your E-Mail Address:
Your Name:
Telephone No.
Address:

  1. The “Principal” is the person granting the power.
    Name of Principal:
    Date of Birth:
    Address:

  2. One or more “Agents” are the person(s) who are granted the power to make decisions for you.
    Name of Primary Agent:
    (The person who will have primary authority to make decisions on your behalf)
    Address:
    Phone Number:
    Relationship: (if any)

  3. If the person I have named above is unable, unavailable, or unwilling to make health care
    decisions for me, I would like the following person to be my agent for making such
    decisions:
    Name of Secondary Agent:
    Address:
    Phone Number:
    Relationship: (if any)

    4. This MINNESOTA PROBATE DATA QUESTIONNAIRE
    is copyrighted by Gary C. Dahle, 2002. All Rights Reserved.