1. Specific Medical Conditions: Section for listing any existing medical conditions, allergies, or specific health concerns - recommended when the patient has known medical issues

2. Limited Authority Exclusions: Section specifying any medical decisions or procedures that are explicitly excluded from the authorization - used when the patient wants to restrict certain types of decisions

3. Alternate Representative: Details of a secondary authorized representative who can act if the primary representative is unavailable - recommended for added security

4. Religious or Cultural Preferences: Section detailing any religious or cultural considerations that should be taken into account in medical decision-making - included when relevant to the patient's beliefs

5. Interpreter Declaration: Section for interpreter details and declaration - required when the form is completed with the assistance of an interpreter

1. Schedule A - Medical History Summary: Optional attachment containing detailed medical history, current medications, and known allergies

2. Schedule B - Specific Treatments Authorization: Detailed list of specific medical treatments or procedures that are pre-authorized or specifically excluded

3. Appendix 1 - Healthcare Provider List: List of current healthcare providers and their contact information

4. Appendix 2 - Identification Documents: Copies of identification documents for both the patient and authorized representative(s)