Please complete and return this Questionnaire to us before your meeting. Thank you.

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* 1. Personal information.

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* 2. Type of Lasting Power of Attorney (Please indicate which type of Lasting Power of Attorney you wish to make).

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* 3. Your Attorneys: We recommend that you appoint at least one but no more than four Attorneys, they do not need to have any specialist skills or experience but it is useful to bear in mind the following guidance (Please tick to acknowledge each statement).

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* 4. Please provide us with your Attorney's details: Attorney 1

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* 5. Please provide us with your Attorney's details: Attorney 2

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* 6. Please provide us with your Attorney's details: Attorney 3

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* 7. Please provide us with your Attorney's details: Attorney 4

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* 8. How do you want your Attorney's to operate in their role?

If you have more than one Attorney, then you can decide whether you want them to act together in making every decision (called a joint appointment), or together and independently, so that they can make decisions together and alone (called a joint and several appointment).

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* 9. Replacement Attorneys. You may also choose to appoint a replacement Attorney to act in place of an original appointed Attorney should they be unable to act for you.

If you wish to appoint replacement Attorney's please complete this section.

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* 10. You must choose in the Personal Welfare Power of Attorney whether you wish your Attorney(s) to be able to give or refuse life-sustaining medical treatment on your behalf. 

The decisions that your Attorney(s) may have to make are based on the circumstances at the time and not the treatment. It does NOT authorise euthanasia.

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* 11. In order for an LPA to be valid, you must choose a person to act as your Certificate Provider. A Certificate Provider is an independent person who certifies that you have the necessary capacity to make the documents and that you are not under any influence or pressure.

We are happy to act for you as Certificate Provider, provided we are not appointed as Attorneys. If you wish to appoint someone else, please let us have their full details. They must be either a professional person, e.g your doctor, or a person who has known you for at least two years.

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* 12. Your advisor will discuss the importance of adding guidance to your LPA(s) setting out how you would like your attorney(s) to act. If you have any specific ideas about what you would or would not like your attorney(s) to do, please provide a brief outline here.

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