HEALTH DIRECTION
Medical Treatment (Health Directions) Act 2006

IMPORTANT NOTICE:
•	If this direction is inconsistent with an enduring power of attorney for a health care matter or a medical research matter that you have previously given, your attorney must comply with this direction.
•	If this direction is inconsistent with an enduring power of attorney for health care matters or medical research matters that you make in the future, your attorney must comply with your enduring power of attorney.
•	You can revoke this direction by clearly expressing to a health professional or someone else a decision to revoke the direction, or by making another direction.
•	Subject to the above, the power to make decisions relating to the withholding or withdrawal of medical treatment to you, including treatment involving medical research, will now be exercised according to your instructions on this form.

1.	DIRECTION
I, 
Person making the direction 	[name]	
	[address]	

make this direction to refuse, or require the withdrawal of,  medical treatment generally or a particular kind of medical treatment:

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

	            			.
2.	PREVIOUS DIRECTION REVOKED 
I revoke all directions previously made by me under the Medical Treatment Act 1994 (if any) and all other directions made by me under the Medical Treatment (Health Directions) Act 2006 (if any).

3.	CERTIFICATION 
I certify that:
(i)  I am an adult;
(ii) I do not have a guardian appointed or have impaired decision-making capacity; and
(iii) this direction is made voluntarily and without inducement or compulsion.
 
Signature of person making direction	
	
Date		

OR
I directed the following person to sign this direction on my behalf –
(Another person can sign the direction on your behalf in your presence if you are unable to sign it yourself.)

Name and address of person signing by direction	[name]	
	[address]	
		
Signature of person signing by direction		
Date		

(It is recommended that you or the person you have directed also sign at the foot of the first page.)

4.	WITNESSES
(The witnesses must sign in the presence of each other and the person making the direction.)
Signature of witness 1		
Name		
Address		
Date		

Signature of witness 2		
Name		
Address		
Date