A durable power of attorney for health care decisions shall be in substantially the following form: (1) The powers of the agent herein shall be limited to the extent set out in writing in this durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural death act. (2) The agent shall be prohibited from authorizing consent for the following items: (3) This durable power of attorney for health care decisions shall be subject to the additional following limitations: This instrument was acknowledged before me on ___ (date) ___ by ___ (name of person) ___. __________________________________ My appointment expires:__________________________ Copies
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