Victorian Consolidated Legislation

Medical Treatment Act 1988 - SCHEDULE 2

Section 5A(2) ENDURING POWER OF ATTORNEY (MEDICAL TREATMENT) THIS ENDURING
POWER OF ATTORNEY is given on the
day of 	19    , by A.B. of 	under section 5A of the Medical Treatment Act 1988.
1. I APPOINT

*C. D. of to be my agent.

*C. D. of to be my agent and E. F. of
to be my alternate agent. (*delete whichever is inapplicable) 2. I AUTHORISE
my agent or, if applicable, my alternate agent, to make decisions about
medical treatment on my behalf. 3. I REVOKE all other enduring powers of
attorney (medical treatment) previously given by me. SIGNED SEALED AND
DELIVERED by:

We ........................... (names of witnesses) each believe that A.B. in
making this enduring power of attorney (medical treatment) is of sound mind
and understands the import of this document. WITNESSED by: (Signature of
Witness) (Signature of Witness) (Name of Witness) (Name of Witness) (Address
of Witness) (Address of Witness) NOTE: Section 5A(2)(a) requires at least one
of the witnesses to this instrument to be a person authorised by law to take
and receive statutory declarations. _______________