1. Mental Capacity Assessment: Required when the patient has cognitive impairments or mental health conditions affecting decision-making capacity

2. Religious or Cultural Preferences: Included when specific religious or cultural considerations need to be taken into account for medical treatment

3. Alternative Decision Makers: Names secondary caregivers or decision-makers if the primary caregiver is unavailable

4. Specific Treatment Exclusions: Lists any specific medical procedures or treatments explicitly excluded from the caregiver's consent authority

5. International Travel Provisions: Required when the patient may need medical care while traveling internationally

6. Communication Protocol: Details how healthcare providers should communicate with multiple family members or caregivers

1. Schedule A - Medical History: Comprehensive medical history of the patient, including current conditions, medications, and allergies

2. Schedule B - Authorized Healthcare Providers: List of pre-approved healthcare providers and facilities

3. Schedule C - Emergency Contacts: Detailed list of emergency contacts and their order of priority

4. Appendix 1 - Identity Documents: Copies of identification documents for all parties

5. Appendix 2 - Medical Power of Attorney: If applicable, copy of any existing Medical Power of Attorney or related legal documents

6. Appendix 3 - Witness Statements: Statements and identification details of witnesses to the consent form signing