DECLARATION AS TO MEDICAL
OR SURGICAL TREATMENT
(CRS 15-18-104.)
I, _________________________ , (name of declarant), being of sound mind and
at least eighteen years of age, direct that my life shall not be artificially prolonged under
the circumstances set forth below and hereby declare that:
1. If at any time my attending physician advanced practice nurse and one other
qualified physician or advanced practice nurse certify in writing that:
a. I have an injury, disease, or illness which is not curable or reversible and
which, in their judgment, is a terminal condition, and
b. For a period of seven consecutive days or more, I have been unconscious,
comatose, or otherwise incompetent so as to be unable to make or communicate
responsible decisions concerning my person, then I direct that, in accordance with
Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the
terms of this declaration, it being understood that life-sustaining procedures shall not
include any medical procedure or intervention for nourishment considered necessary by
the attending physician to provide comfort or alleviate pain. However, I may specifically
direct, in accordance with Colorado law, that artificial nourishment be withdrawn or
withheld pursuant to the terms of this declaration.
2. In the event that the only procedure I am being provided is artificial
nourishment, I direct that one of the following actions be taken:
_______ (initials of declarant) a. Artificial nourishment shall not be continued
when it is the only procedure being provided; or
_______ (initials of declarant) b. Artificial nourishment shall be continued for
_________ days when it is the only procedure being provided; or
_______ (initials of declarant) c. Artificial nourishment shall be continued when it
is the only procedure being provided.
(Optional) I hereby make an anatomical gift, to be effective upon my death, of:
A. _______ Any needed organs/tissues
OR
B. _______ The following organs/tissues:
_____________________________
_____________________________
_____________________________
Donor signature: ___________________________________________
3. I execute this declaration, as my free and voluntary act, this _____ day of
____________________ , 20 _____ .
By___________________________
Declarant
The foregoing instrument was signed and declared by
_________________________ to be his/her declaration, in the presence of us, who, in
his/her presence, in the presence of each other, and at his/her request, have signed our
names below as witnesses, and we declare that, at the time of the execution of this
instrument, the declarant, according to our best knowledge and belief, was of sound mind
and under no constraint or undue influence.
We further declare that neither of us is : 1) a physician; 2) the declarant’s
physician or an employee of his/her physician; 3)an employee or a patient of the health
care facility in which the declarant is a patient; or 4) a beneficiary or creditor of the estate
of the declarant .
Dated at, Colorado, this _____ day of _____________ , 20 _____ .
___________________________________ ___________________________________
Name Name
___________________________________ ___________________________________
Address Address
OPTIONAL
STATE OF COLORADO )
) ss.
County of ______________ )
SUBSCRIBED and sworn to before me by _______________ , the declarant, and
__________________ and _____________________ , witnesses, as the voluntary act and
deed of the declarant this _____ day of ________________ , 20 _____ .
My commission expires:
_________________________
Notary Public
Useful tips for finalizing your ‘Health Declaration’ online
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Adhere to this detailed tutorial:
Access your account or initiate a free trial with our service.
Select +Create to upload a file from your device, cloud storage, or our template library.
Open your ‘Health Declaration’ in the editor.
Click Me (Fill Out Now) to finalize the form on your side.
Include and assign fillable fields for additional users (if required).
Proceed with the Send Invite settings to solicit eSignatures from others.
Download, print your version, or convert it into a multi-use template.
No need to worry if you must work with your associates on your Health Declaration or send it for notarization—our platform provides everything you require to accomplish such tasks. Sign up with airSlate SignNow today and take your document management to a new level!
FAQs
Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.
A health declaration form is a document used to collect information about an individual's health status, often required for travel, employment, or access to specific venues. It is essential as it helps organizations assess health risks and ensure the safety of all individuals involved. Utilizing an electronic solution like airSlate SignNow streamlines the process of collecting and managing these forms securely.
airSlate SignNow provides an intuitive platform for creating, sending, and eSigning health declaration forms. With its user-friendly interface, you can easily customize templates, collect responses, and store completed forms securely. This not only saves time but also enhances compliance with health regulations.
Yes, airSlate SignNow offers various pricing plans to fit your business needs, including options specifically designed for managing health declaration forms. Each plan includes features that help you effectively send, sign, and store documents. You can choose a plan that best aligns with your budget and requirements.
airSlate SignNow offers features such as customizable templates, secure eSigning, real-time tracking, and integration with other applications to manage health declaration forms efficiently. These features ensure that you can handle the entire process seamlessly, from creation to completion.
Absolutely! airSlate SignNow provides integration capabilities with various software applications, allowing you to connect your health declaration forms with tools like CRM systems, document management platforms, and more. This integration enhances workflow efficiency and data management.
The security of your data is a top priority at airSlate SignNow. All information collected through health declaration forms is encrypted and stored in compliance with industry standards, ensuring that sensitive health information remains confidential and protected from unauthorized access.
Various organizations, including hospitals, schools, and businesses, can benefit from using airSlate SignNow for health declaration forms. Whether for employee onboarding, event attendance, or travel screening, the platform simplifies the management of health declarations, making it suitable for a wide range of industries.
The best way to complete and sign your health declaration form
Save time on document management with airSlate SignNow and get your health declaration form eSigned quickly from anywhere with our fully compliant eSignature tool.
How to complete and sign documents online
Previously, coping with paperwork required lots of time and effort. But with airSlate SignNow, document management is easy and fast. Our robust and easy-to-use eSignature solution lets you effortlessly complete and electronically sign your health declaration form online from any internet-connected device.
Follow the step-by-step guide to eSign your health declaration form template online:
1.Sign up for a free trial with airSlate SignNow or log in to your account with password credentials or SSO authentication.
2.Click Upload or Create and add a form for eSigning from your device, the cloud, or our form catalogue.
3.Click on the file name to open it in the editor and use the left-side menu to fill out all the blank fields accordingly.
4.Place the My Signature field where you need to approve your form. Type your name, draw, or upload a picture of your handwritten signature.
5.Click Save and Close to accomplish modifying your completed document.
As soon as your health declaration form template is ready, download it to your device, export it to the cloud, or invite other people to eSign it. With airSlate SignNow, the eSigning process only takes a few clicks. Use our robust eSignature tool wherever you are to manage your paperwork effectively!
How to complete and sign paperwork in Google Chrome
Completing and signing documents is simple with the airSlate SignNow extension for Google Chrome. Adding it to your browser is a quick and effective way to deal with your paperwork online. Sign your health declaration form sample with a legally-binding eSignature in just a few clicks without switching between tools and tabs.
Follow the step-by-step guide to eSign your health declaration form in Google Chrome:
1.Go to the Chrome Web Store, locate the airSlate SignNow extension for Chrome, and add it to your browser.
2.Right-click on the link to a document you need to sign and select Open in airSlate SignNow.
3.Log in to your account with your password or Google/Facebook sign-in buttons. If you don’t have one, you can start a free trial.
4.Utilize the Edit & Sign menu on the left to complete your sample, then drag and drop the My Signature option.
5.Add a picture of your handwritten signature, draw it, or simply type in your full name to eSign.
6.Verify all data is correct and click Save and Close to finish modifying your form.
Now, you can save your health declaration form template to your device or cloud storage, send the copy to other people, or invite them to eSign your form with an email request or a secure Signing Link. The airSlate SignNow extension for Google Chrome enhances your document workflows with minimum time and effort. Start using airSlate SignNow today!
How to complete and sign forms in Gmail
Every time you receive an email containing the health declaration form for signing, there’s no need to print and scan a document or save and re-upload it to another tool. There’s a much better solution if you use Gmail. Try the airSlate SignNow add-on to promptly eSign any documents right from your inbox.
Follow the step-by-step guidelines to eSign your health declaration form in Gmail:
2.Install the program with a related button and grant the tool access to your Google account.
3.Open an email containing an attachment that needs approval and utilize the S key on the right sidebar to launch the add-on.
4.Log in to your airSlate SignNow account. Select Send to Sign to forward the file to other parties for approval or click Upload to open it in the editor.
5.Place the My Signature field where you need to eSign: type, draw, or upload your signature.
This eSigning process saves efforts and only takes a couple of clicks. Utilize the airSlate SignNow add-on for Gmail to adjust your health declaration form with fillable fields, sign forms legally, and invite other individuals to eSign them al without leaving your inbox. Boost your signature workflows now!
How to fill out and sign forms in a mobile browser
Need to quickly complete and sign your health declaration form on a mobile phone while working on the go? airSlate SignNow can help without the need to set up additional software apps. Open our airSlate SignNow tool from any browser on your mobile device and create legally-binding eSignatures on the go, 24/7.
Follow the step-by-step guidelines to eSign your health declaration form in a browser:
1.Open any browser on your device and follow the link www.signnow.com
2.Register for an account with a free trial or log in with your password credentials or SSO option.
3.Click Upload or Create and pick a file that needs to be completed from a cloud, your device, or our form catalogue with ready-to go templates.
4.Open the form and fill out the empty fields with tools from Edit & Sign menu on the left.
5.Place the My Signature field to the form, then type in your name, draw, or upload your signature.
In a few easy clicks, your health declaration form is completed from wherever you are. When you're done with editing, you can save the document on your device, generate a reusable template for it, email it to other individuals, or ask them to eSign it. Make your documents on the go quick and efficient with airSlate SignNow!
How to complete and sign forms on iOS
In today’s business world, tasks must be completed quickly even when you’re away from your computer. With the airSlate SignNow app, you can organize your paperwork and sign your health declaration form with a legally-binding eSignature right on your iPhone or iPad. Install it on your device to close deals and manage forms from just about anywhere 24/7.
Follow the step-by-step guide to eSign your health declaration form on iOS devices:
1.Go to the App Store, search for the airSlate SignNow app by airSlate, and install it on your device.
2.Open the application, tap Create to import a template, and choose Myself.
3.Choose Signature at the bottom toolbar and simply draw your signature with a finger or stylus to eSign the sample.
4.Tap Done -> Save after signing the sample.
5.Tap Save or take advantage of the Make Template option to re-use this document later on.
This process is so straightforward your health declaration form is completed and signed in a few taps. The airSlate SignNow app works in the cloud so all the forms on your mobile device remain in your account and are available whenever you need them. Use airSlate SignNow for iOS to improve your document management and eSignature workflows!
How to complete and sign forms on Android
With airSlate SignNow, it’s easy to sign your health declaration form on the go. Set up its mobile app for Android OS on your device and start enhancing eSignature workflows right on your smartphone or tablet.
Follow the step-by-step guidelines to eSign your health declaration form on Android:
1.Navigate to Google Play, search for the airSlate SignNow application from airSlate, and install it on your device.
2.Log in to your account or create it with a free trial, then import a file with a ➕ key on the bottom of you screen.
3.Tap on the imported document and select Open in Editor from the dropdown menu.
4.Tap on Tools tab -> Signature, then draw or type your name to eSign the form. Fill out empty fields with other tools on the bottom if needed.
5.Utilize the ✔ button, then tap on the Save option to finish editing.
With an intuitive interface and full compliance with main eSignature requirements, the airSlate SignNow app is the perfect tool for signing your health declaration form. It even operates without internet and updates all record changes when your internet connection is restored and the tool is synced. Fill out and eSign documents, send them for eSigning, and generate re-usable templates whenever you need and from anyplace with airSlate SignNow.
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