Health Care Power of Attorney AboutThe health care power of attorney is a document in which you designate someone to be your representative, or agent, in the event you are unable to make or communicate decisions about all aspects of your health care.PriceKsh 7,540 Step 1 of 13 7% Who is the Principal?*NameAddressNational Identity number/Passport Number Save and Continue Later Who is the Health Care Agent?*NameAddressPhone NumberNational Identity/Passport Number Save and Continue Later Who is the doctor(s) in care of your health?* The doctors may be two. They will be the ones who will determine the state of your mental health thereby giving effect to this Power of Attorney Save and Continue Later Under what circumstances will the Health care Agent withdraw artificial nutrition?* The rule in this POA is that the Health Care Agent is not allowed to withdraw or refuse you artificial nutrition; but you may vary this under certain circumstances. Save and Continue Later Under what circumstances will the Health care Agent withdraw artificial hydration?* The rule in this POA is that the Health Care Agent is not allowed to withdraw or refuse you artificial hydration; but you may vary this under certain circumstances. Save and Continue Later Are there certain limitations that the Health care agent is bound by in regard to health care decisions?* Here you may include any specific you deem appropriate such as: your own definition when life‑prolonging measures should be withheld or discontinued, or instructions to refuse any specific types of that are inconsistent with your religious beliefs, or are unacceptable to you for any other reason Save and Continue Later Are there certain limitations that the Health care agent is bound by in regard to mental health decisions?* Here you may include any provisions you deem appropriate such as: limiting grant of authority to make only mental health treatment, your own instructions regarding the administration withholding of psychotropic medications and treatment (ECT), regarding admission to and retention in a health care facility for health treatment, or instructions to refuse any specific of treatment that are unacceptable to you. Save and Continue Later Do you have any advanced instructions in regard to your mental health treatment?* Save and Continue Later What organs do you wish to have donated by your health care Agent?* Save and Continue Later Any instructions to your health care agent in regard to your organ donation? Save and Continue Later What is the Effective date of this Power of Attorney?*Kindly enter in this format: 12th day of December 2016 Save and Continue Later Who is the Witness to this Power of Attorney?*NameAddressNational Identity/Passport Number Save and Continue Later Select the payment Mode*MpesaAirtel MoneyCurrently we only support Mpesa and Airtel Money. Send Airtel Money Ksh. 7,540.00 to nick-name Uwakili. Submit the Transaction ID below. Go to Airtel Money option on your phone Select Send Money Option Select Enter Nick-Name Option Type the name Uwakili Enter the Amount Ksh. 7,540.00 Confirm Amount and Nickname Enter your PIN and Send You will receive a confirmation SMS from Airtel Money with a Transaction ID After you receive the confirmation SMS, enter your phone number and the Transaction ID Click on Complete Send M-PESA Ksh. 7,540.00 to Buy Goods and Services Till number 239230. Submit the Confirmation Code below. Go to M-PESA on your phone Select Buy Goods and Services option Enter Till no. 239230 Enter the Amount Ksh. 7,540 Enter your M-PESA PIN and Send You will receive a confirmation SMS from M-PESA with a Confirmation Code After you receive the confirmation SMS, enter your phone number and the Confirmation Code Click on Complete Phone number*Input phone number in the following format: 2547xxxxxxxx, where x refers to your mobile number.Transaction code*This is the code you receive after successfully sending money.CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.