Every adult should have a Living Will, a Health Care Power of Attorney, and if desired, a signed organ donor consent form. Together these are known as “Advance Directives.”  Advance Directives are the best way to ensure that decisions about your health and well-being are made by someone you choose and in a manner consistent with your wishes. On this page you can complete an online questionnaire and we will prepare these documents for you. Go to online questionnaire.            Click here if you have questions about Advance Directives.

Go to online questionnaire.

Go to online questionnaire.

Representation Disclaimer: Anyone involved in a legal dispute in which the firm of Bish, Butler & Thompson, Ltd represents an adverse party should not complete this questionnaire. This questionnaire should not be completed by anyone who is presently being assisted by another attorney with respect to Advance Directives. The completion and submission of this questionnaire does not create an attorney/client relationship. You may also call the firm at 419-636-5666 to speak to an attorney before you complete the questionnaire if you desire.

Go to online questionnaire.

BEGIN HERE: ONLINE ADVANCE DIRECTIVE QUESTIONNAIRE

CLIENT INFORMATION:

*Your First Name Your Middle Initial

*Your Last Name

*email

*Date of Birth (e.g. 01/23/1963)

*Social Security Number

Suite/ P.O. box

*Street

*City     *State      *Zip Code 

HEALTH CARE AGENTS:

In your documents you must specify an “Agent”. This is the person you designate to make health care decisions for you if you are unable to do so for yourself. You should also choose at least one alternate. Most people choose a spouse or their child(ren); however, you are free to choose just about anyone other than your doctor or an administrator of a health care facility where you might be treated.

Primary Agent Information (required):

*Agent First Name   Agent Middle Initial

*Agent Last Name

Suite/ P.O. box

*Street

*City   *State   *Zip Code

Agent Telephone

Agent email

First Alternate Agent Information (optional):

Do you want to select an alternate agent who will serve if your first choice listed above cannot? (recommended but not required)  

Yes    No - skip to next section ____________________________________________________________________

First Alternate Agent First Name   First Alt. Agent Middle Initial

First Alternate Agent Last Name

Street

Suite/ P.O. box

City   State     Zip Code

First Alternate Agent Telephone

email

Second Alternate Agent Information (optional):

Do you want to select a second alternate agent who will serve if your first and second choices listed above cannot? (not required) 

Yes    No - skip to next section ____________________________________________________________________

Second Alternate Agent First Name   Second  Alt. Agent Middle Initial

Second  Alternate Agent Last Name

Street

Suite/ P.O. box

City   State  Zip Code

Second Alternate Agent Telephone

email

   ORGAN DONOR INFORMATION:

     Do you want to be an organ donor?   

      Yes     No - skip to next section

      ____________________________________________________________________

    Body parts you wish to donate:

      Driver’s License or ID Card No:

DOCTOR INFORMATION:

Do you want to us to send a copy of your Advance Directives to your Doctor?

Yes   No - skip to next section         

____________________________________________________________________

Doctor First Name (if Known)  

Doctor Last Name

Doctor Address:

Bryan Medical Group

Other -- Specify the facility name and complete address for your doctor: