Filling out a form to document health care decisions.

Forms to Document Health Priorities & Choices

Available forms to appoint a health care agent, specify care and treatment preferences, submit documents to Vermont's Advance Directive Registry, and related to Vermont's law on medical aid in dying.

Helpful tip:

After you select your form, please download and save the blank form to your computer before you begin completing it. Changes made to the form before downloading and saving it to your device will not be preserved online.

Advance Directives for Health Care

Appointment of a Health Care Agent Form

Enables you to appoint a health care agent who will be authorized to make medical decisions for you if you are unable to speak for yourself.

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Advance Directive Short Form

Enables you to appoint a health care agent and provide detailed information about your health care goals and treatment priorities.

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Advance Directive Long Form

The original Vermont Advance Directive. Enables you to appoint a health care agent, provide detailed instructions about your care, and includes provisions for those with mental health and/or psychiatric considerations.

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PREPARE for Your Care Advance Directive (English)

Visit the PREPARE website for easy to read advance directives developed by the PREPARE program based in California (English version). Advance Directive template are available for all 50 states, including Vermont.

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Disability Rights Vermont Advance Directive

Produced by Disability Rights Vermont for individuals seeking to include information about mental health preferences and decisions.

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VT Department of Disabilities, Aging and Independent Living: Appointment of a Health Care Agent

This form may be used for people with developmental disabilities who want to appoint a health care agent, but may not be able to describe detailed advance directives.

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Medical Orders (Vermont DNR/COLST Form)

A medical order completed by your clinician to limit the use of life sustaining treatments at end of life. Based on your medical condition, your values, and your wishes.

DNR/COLST Form

Updated in June 2022, this is the most current version of the VT DNR/COLST. This is a medical order completed by your clinician with your consent, or the consent of your surrogate decision-maker. DNR/COLST stands for Do-Not-Resuscitate/Clinician Orders for Life-Sustaining Treatment

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Vermont Advance Directive Registry (VADR): Forms & Submission Instructions

Directives submitted to the VT Advance Directive Registry via mail, fax or email require the VADR Registration Agreement and Authorization to Change form. Follow instructions on the form to find out how to submit your directive to the VADR. Older versions of this form, which was previously separated into two documents (Registration Agreement form, Authorization to Change form) are still valid.

VADR Registration Agreement and Authorization to Change Form

Required when submitting new or updated documents to the VADR via mail, fax or email. NOT required for USER UPLOAD. Allows for your document to be accessed electronically by providers nationwide.

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Provider Access to the VADR

For health care providers, accessing the VADR is a statutory responsibility. To become an authorized user of the VADR, complete & submit the application form in order to receive your access information.

Provider Access Application Application Overview Page

July 1, 2024 - Updates to VADR Policies and Procedures

New submission options, website features and customer service locations have taken effect on July 1, 2024. Read more about the changes here.

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Forms for Patient Choice & Control at End of Life (Act 39)

Physician Reporting

Enables a prescribing physician to document the legal steps required under Vermont's Medical Aid in Dying Law.

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Consulting Physician Reporting

Enables a consulting physician to document the legal steps required under Vermont's Medical Aid in Dying Law.

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Patient Written Request for Medication

Enables patients to complete the written request required by Vermont's Medical Aid in Dying Law.

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Physician Follow-Up Reporting

Required for prescribing physicians who write a prescription for a lethal dose of medication under Vermont's Medical Aid in Dying Law.

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