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Special Power Of Attorney
(For Medical Authorization)
I, [Name], of [Address], hereby appoint [Name] with offices located at [Address], as my attorney in fact to act in my capacity to do any and all of the following:
1. Make any and all decisions and authorize all procedures that [Enumerate] may deem necessary regarding the medical treatment of my children, [Name] and/or [Name].
The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect and shall remain in full force and effect until [Date] or unless specifically extended or rescinded earlier by either party.
Insert Full Name
This Section for Notary:
STATE OF -------)
) ss: [Date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]