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Made by          

of                           , Alberta.

1.         Who is my health-care agent and alternate?

a)   I appoint        

of          , Alberta, as my health-care agent pursuant to the Personal Directives Act.

b)      If he or she is unwilling or unable to act, then I appoint        

       of        ,

Alberta, as my health-care agent in his or her place.

2.         When does this appointment become effective?

a)      This directive will only be in effect if, and only as long as, I am unable to make or communicate my own decisions about my health or personal care due to lack of capacity.

b)   A declaration by        

of        , Alberta, will be sufficient proof that I lack the capacity to make or communicate my own health- or personal-care decisions.

c)   If  he or she is unable or unwilling to make a determination about my capacity, or cannot be reached after every reasonable effort has been made, then a written declaration signed by two physicians who are familiar with my circumstances will suffice.


3.         How will my agent make decisions for me?

a)   If I am able to communicate in any way (including by gestures as well as by speaking or writing), then this directive will have no effect and my instructions are to be followed.

b)   If I am unable to communicate, my agent is to follow the instructions I have given below.

c)   If I have not left instructions on the issue at hand, then my agent is to make for me the decisions I would have made for myself, based on my agent’s knowledge of my wishes, values, and beliefs.

d)   If my agent does not know what my wishes, beliefs, and values are with respect to a particular issue, then he or she is to make the decision that he or she believes is in my best interests under the circumstances.


4.         What specific decision-making powers does my agent have?

I give my agent power to make decisions about the following personal and health-care matters:

a)   My health care which includes, but is not limited to, power to —

i.      consent, refuse, or withdraw consent to any type of health care;

ii.      review my medical records and consent to their disclosure to others;

iii.      authorize my admission to or discharge from any medical or care facility;

iv.      obtain health-care services on my behalf;

v.      hire or fire people to care for me;

vi.      sign any waivers, releases, or permissions required by anyone who is providing health-care service to me.

b)   Accommodation and living arrangements

c)   With whom I may live and associate

d)   Participation in social, educational, and employment activities

e)   Legal matters not relating to my estate


5.         What are my instructions about end-of-life treatments?

(Insert clause chosen from Sample 1.)



6.         My signature

I confirm that I understand this document and the power it gives to my agent.

DATED at                           , Alberta, this     day

of                           , 20                          .


(Signature of maker)



(Print name of maker)



(Signature of witness)



(Print name of witness)






I,                           ,

of                           , Alberta, the person designated in the attached personal directive to determine the maker’s capacity, declare that I have consulted with the physician or psychologist indicated below and I am of the opinion that the maker is not competent to make decisions about the following areas:

a)   Health care

b)            Accommodation and living arrangements

c)   With whom to live and associate

d)            Participation in social, educational, and employment activities

e)   Legal matters not relating to the estate.

For the following reasons:           







(Signature of designated person)


(Print name of designated person)


(Address of designated person)


(Phone number of designated person)