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DECLARATION OF INCAPACITY BY TWO PHYSICIANS

 

We declare that                           (name of maker) lacks capacity to make decisions with respect to his or her health and personal care based on the following reasons:

 

 

Diagnosis:

Prognosis: 

 

 

                       

(Signature of physician)

                       

(Print name of physician)

                       

(Office address)

                       

(Phone number)

                       

(Date)

 

 

                       

(Signature of physician)

                       

(Print name of physician)

                       

(Office address)

                       

(Phone number)

                       

(Date)