I, the undersigned, [First Name Last Name] , [date of birth] , [skill]

Designated to assist me in case of need as a trusted person

Mr./Mrs. [First Name Last Name] ,

Born on [date of birth]

Resident [skill]

[telephone]

[email address]

Relationship with the person: parent/doctor/close friend

This designation shall be valid without limitation of time until I decide otherwise or the person of trust provides otherwise. This designation is reviewable and revocable at any time.

I have noted that Mr. / Mrs. [First Name Last Name]  :

• May, at my request, accompany me in the steps concerning my care and attend the medical interviews
• May be consulted by the team treating me in case I am not able to express my will regarding the care provided to me and must receive the necessary information to do so. In these circumstances, no major intervention can be carried out without this prior consultation except in case of urgency or impossibility to reach him/her
• Will not receive information that I consider confidential and that I have indicated to the doctor
• will be informed by me of this designation and that I will have to ensure its agreement
• can help me to know and understand my rights if I encounter difficulties.

I can end this decision at any time and by any means.

Done at [location] , on [date]

Your signature

Signature of Designated Person