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1. Specific Medical Conditions: Include when the proxy consent relates to specific known medical conditions or treatments

2. Religious or Cultural Preferences: Include when specific religious or cultural considerations should guide medical decisions

3. Emergency Contact Information: Include when additional emergency contacts beyond the proxy need to be specified

4. Revocation Clause: Include when specific conditions for revocation need to be outlined beyond standard legal provisions

1. Schedule A - Medical History: Optional schedule containing relevant medical history and current conditions of the grantor

2. Schedule B - Specific Treatments: List of specific medical treatments or procedures for which proxy consent is explicitly granted or withheld

3. Appendix 1 - Identification Documents: Copies of identification documents for all parties involved

4. Appendix 2 - Medical Provider Information: List of current healthcare providers and medical facilities regularly used by the grantor