Please enable JavaScript in your browser to complete this form.Date Your Full NameAddressDate Of BirthMobile/Other Telephone NoENDURING POWER OF ATTORNEY You can choose more than one attorney if desired. Please list below who you are appointing as your attorney/s? Attorney (1)Full Name Attorney (1)Address Date of Birth Email Address Mobile/Telephone No.Act jointly?Act jointly & severally? Attorney (2) Full Name Attorney (2)Address Date of BirthEmail AddressMobile/Telephone No.Act jointly?Act jointly & severally? In the event your appointed attorney/s cannot or is not willing to act as attorney/s, please list below who you would like to appoint as an alternative attorney/s “Alternative” Attorney (1) Full Name (Alternative Attorney (1))Address Date of BirthEmail AddressMobile/Telephone No.Act jointly?Act jointly & severally? “Alternative” Attorney (2) Full Name ( Alternative Attorney (2))Address Date of BirthEmail AddressMobile/Telephone No.Act jointly?Act jointly & severally? Select below when the Power of Attorney is to commence?ImmediatelyUpon you losing capacityAt another specific timeProvide any specific instructions to give your power of attorney/s You place the following limits and/or conditions on the authority of your attorney/s (if applicable) MEDICAL TREATMENT DECISION MAKERYou can nominate more than one Medical Treatment Decision Maker. However, please note that only one person can act as decision maker at any one time. Accordingly, the first person listed as your Medical Treatment Decision Maker, will be the first point of contact if a medical decision is required and you lack capacity. Medical treatment decision maker (1) Full Name (Medical treatment decision maker (1))Address Date of BirthEmail AddressMobile/Telephone No. Medical treatment decision maker (2) Full Name (Medical treatment decision maker)Address Date of BirthEmail AddressMobile/Telephone No. Please do not hesitate to contact our office on 9670 7440 if you require assistance completing this Questionnaire. Leave this field empty Submit