Advance Directive

Advance Directive Acknowledgement Form

An Advance Directive is a legal document allowing a person to give directions about future medical care or to designate another person(s) to make medical decisions if he or she should lose decision making capacity.

  1. You have the right to give written directions about future treatment before you become seriously ill or unable to make healthcare decisions. This is called an “Advance Directive”.
  2. You have the right to accept or refuse medical or surgical treatment.
  3. An employee of the SHCC Patient Registration Department will provide you with information to help you develop an Advance Directive regarding your healthcare. You are not required to make any Advance Directive about your future medical treatment. This practice is completely voluntary. It is entirely your choice.
  4. You may consult your doctor, family, lawyer, or others before making a written Advance Directive.
  5. If you decide to make an Advance Directive about future medical care it will become a part of your medical record at SHCC. Photocopies of your fully executed and witnessed directive should be made for your personal records, your family members and your proxy and alternate if you have chosen them. The original or a copy should be furnished to your hospital of choice whenever you receive inpatient care.
  6. You may revoke your Advance Directive at any time, in writing or simply by telling your attending physician or other healthcare provider or a witness, regardless of your physical or mental condition.


I understand my rights as set forth above.  Please check one of the following statements:

If you do not have an Advance Directive: 

If you do have an Advance Directive, please email it to [email protected] 

Note: It is the patient’s responsibility to provide SHCC with a copy of any Advance Directive document (living will, health care proxy, or medical power of attorney) or other document that could affect your care, if such document(s) exist.


Patient Name:

Patient DOB: //


Leave this empty:

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Signature Certificate
Document name: Advance Directive
lock iconUnique Document ID: 6b8d30581dec0ca32ff03b3eead82304cc2a16e1
Timestamp Audit
April 23, 2020 9:50 am EDTAdvance Directive Uploaded by Darren Huff - [email protected] IP