This document is an enduring power of attorney (medical) form specific to Victoria, Australia, allowing a designated agent to make medical treatment decisions for the donor in case of incapacity. The donor can select one or two agents, specifying a primary and an alternate agent if desired. It emphasizes the revocation of any prior medical enduring powers of attorney and provides instructions for completion.

1. DOCUMENT SUMMARY
I appoint my agent(s) to make
decisions about my medical
treatment if I lose capacity (for
example, if I become unconscious
or have a brain injury). This
appointment is made in Victoria,
Australia.
USING THIS FORM
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This form is of a general nature
only and may not be suitable for
specific circumstances.
ENDURING POWER
OF ATTORNEY
(MEDICAL)
VICTORIA
© Legal Zebra 2014 | Form 6675 | legalzebra.com.au
SAM
PLE

2. Page 1 of 2
Enduring Power of Attorney (Medical) Victoria
1 This document
THESE TIPS
Follow these tips to complete the
document. They will appear on
screen but not in the printed
document.
YOU ARE THE DONOR
As the person who is making this
Power of Attorney you are
referred to as the “donor”.
This Enduring Power of Attorney (Medical) is made under Section 5A
of the Medical Treatment Act 1988 Victoria. It is made as a deed on
the date it is signed by me, the donor.
My name and address
FULL LEGAL NAME OF DONOR
STREET ADDRESS OF DONOR
2 Appointment of Agents
APPOINTING AN AGENT
Select A if you want decisions
about your medical treatment to
be made solely by Agent 1. If you
select option A, do not fill in the
details for Agent 2.
Select B if you want Agent 1 to
make decisions about your
medical treatment but if Agent 1
is unable to act (for example,
because he or she loses
capacity, dies or is overseas)
then you want Agent 2 to act in
place of Agent 1.
A I appoint Agent 1 to be my sole agent.
B I appoint Agent 1 to be my agent and Agent 2 to be my
alternative agent.
Agent 1
FULL LEGAL NAME OF AGENT 1
STREET ADDRESS OF AGENT 1
Agent 2 (if applicable) SUBSTITUTE AGENT
Only fill in details for Agent 2 if
you selected B above.
FULL LEGAL NAME OF AGENT 2
STREET ADDRESS OF AGENT 2
3 Donor’s Authorisation
I authorise my agent or, if applicable, my alternate agent, to make
decisions about medical treatment on my behalf.
I revoke all other enduring powers of attorney (medical treatment)
previously given by me.
© Legal Zebra 2014 | Form 6675 | legalzebra.com.au

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