Wishes For My Care Form

The Video version of your advance directive allows you to make many more choices about the care you will want for yourself in the case that you are incapacitated. The Wishes for My Care form gives you suggestions for your care. You can download it or print it and make your selections. You can also create options of your own. Once you have filled out this form you can use it as a guide while making your video.

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Patient Data Form

This is the first form you will need to complete to get started with the In My Own Words®, Advance Directive Video Recording Service. This form asks for basic information about you, your designated power of attorney, physician, attorney, and family members.

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Consent to Participate Form

This form acknowledges your consent to participate in the In My Own Words®, Advance Directive Video Recording Service. This form needs to be completed and sent in with the Patient Data Form in order to start the application process.

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Release of Information Form

In order for the In My Own Words®, Advance Directive Video Recording Service, to have contact with your family, your designated Health Care Agent, your attorney, or medical provider, you must first give us written permission. Once you have signed these forms we will be able to send copies of your Video to anyone that you select.

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Please fill out a separate form for each person you wish for us to contact.