Patient Advance Directive Inquiry Form

Patient Advance Directive Inquiry Form — Form Fields

This healthcare template includes 9 fields. Allow patients to express interest in creating an advance directive or living will with support from care coordinators. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Date of Birth (text, required)
• Do you currently have an advance directive or living will? (multiple choice, required) — options: Yes, No, Unsure
• Do you have a designated healthcare proxy or power of attorney? (multiple choice, required) — options: Yes, No, Unsure
• What prompted this inquiry? (dropdown selection, required) — options: Recent diagnosis, General planning, Physician recommendation, Family discussion, Other
• Would you like to speak with a care coordinator? (multiple choice, required) — options: Yes, No - just want information
• Questions or specific concerns (long text, optional)