1. Alternate Decision Maker: Secondary person authorized to make decisions if the primary person is unavailable

2. Religious or Cultural Preferences: Specific religious or cultural considerations that should be taken into account in medical treatment

3. Living Will Reference: Reference to any existing living will or advance directive, if applicable

4. Specific Treatment Exclusions: List of any treatments or procedures specifically refused by the patient

5. Mental Capacity Assessment: To be included if there are concerns about the patient's current or future mental capacity

6. Revocation Clause: Specific terms under which the consent can be revoked by either party

1. Schedule A - Medical History: Detailed medical history including past surgeries, conditions, and treatments

2. Schedule B - Current Medication List: Comprehensive list of current medications, dosages, and prescribing doctors

3. Schedule C - Emergency Protocol: Specific steps to be followed in various types of medical emergencies

4. Appendix 1 - Certified Copies: Certified copies of ID documents for all parties involved

5. Appendix 2 - Medical Certificates: Any relevant medical certificates or reports supporting the need for the consent arrangement

6. Appendix 3 - Legal Capacity Certificate: If required, a certificate from a medical professional confirming the elderly parent's capacity to grant consent