Health Care Surrogate

HEALTH CARE SURROGATE QUESTIONNAIRE (FEE $40)

Person Giving Authority

Your Contact Email Address: *
Name of person giving authority: *Please type your full first and last name
Best Contact Phone Number: *
Complete Address: *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Of Birth: *

Person Receiving Authority:

Name Of Person Receiving Authority *Please type in full first and last name
Relationship To Person Listed As Person Giving Authority *
Date Of Birth: *
Complete Address: *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Other Person Receiving Authority

Disclaimer Any other Names of person(s) receiving authority (if applicable) All person(s) listed below will have the same authority as each person(s) named in "Name Of Person Receiving Authority" above:
Name Of Other Person Receiving Authority Please type in full first and last name
Relationship To Person Listed As "Name Of Person Giving Authority"
Complete Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Of Birth:

Additional Other Person Receiving Authority

Name Of Additional Other Person Receiving Authority
Relationship To Person Listed As "Name Of Person Giving Authority"
Complete Address:
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Of Birth:
RELEASE OF LIABILITY *
Please read the information below and by clicking on EACH CHECK BOX below acts as you read and agree to the terms below. I have been informed by the Staff of Express L C L Services, Inc. d/b/a Express Non Lawyer that:They ARE NOT ATTORNEYS, & they CANNOT GIVE LEGAL ADVICE.They are only assisting me in the proper preparation of these documents so that I can represent myself in this matter without an attorney.They have further informed me that legal representation by an attorney would advise me of all legal rights that I may have arising out of this action.The legal documents prepared by Express L C L Services, Inc. d/b/a Express Non Lawyer,have been prepared in accordance with the information provided by me in my desire to represent myself in this transaction.I declare:That the information provided by me is true and complete to the best of my knowledge and belief;That I agree to review all documents prepared and my signature is acknowledgment of my approval of all documents;That I hereby release Express L C L Services, Inc. d/b/a Express Non Lawyer, from any liability arising out of the services performed for me by them as the result of my failure to provide the information requested or to thoroughly review all documents. I further declare that I am signing this document without undue influence, threat or pressure from any person or entity involved in the outcome of this transaction.I understand that any and all payments made to Express L C L Services, Inc. d/b/a Express Non Lawyer, for the preparation of any documents are non-refundable and that I have been informed that I must pick up my documents within 90 days of completion or the documents maybe destroyed and/or I may incur additional fees as determined applicable by the Staff of Express L C L Services, Inc. d/b/a Express Non Lawyer.
By Entering Date & Name below, I hereby agree to the terms listed in the RELEASE OF LIABILITY.
Your First & Last Name *
Today's Date *

Are you a human?

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Health Care Surrogate

Express NonLawyer

Phone:

(321) 729-6399

Address:

Email Us:

Business Hours:

Please note:

Health Care Surrogate

HEALTH CARE SURROGATE QUESTIONNAIRE (FEE $40)

Person Giving Authority

Person Receiving Authority:

Other Person Receiving Authority

Additional Other Person Receiving Authority

Are you a human?

Health Care Surrogate