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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:

Upon download of a form, please save a blank copy to your computer prior to filling it out to ensure that your information is retained.

Advance Directives for Health Care & Medical Orders

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

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)

Easy to read advance directive developed for Vermont by the PREPARE program based in California (English version).

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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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DNR/COLST Form (NEW! 2022 Updated Form)

Effective June 1, 2022. 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.

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

All submissions to the VT Advance Directive Registry 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. Allows for your document to be accessed electronically by providers nationwide.

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VADR Electronic Submission Instructions

Instructions to e-mail your advance directive to the Vermont Advance Directive Registry.

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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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Looking for an advance directive form in another language?

The forms below are full translated versions of both the Appointment of a Health Care Agent form and the Advance Directive Short form. Both forms allow for the appointment of a health care agent. All files also include the VADR Registration Agreement and Authorization to Change form. If you don't see the language you need, you may use any form you choose, even those from other states, so long as you follow Vermont’s witnessing requirements (i.e. for outpatients: 2 witnesses who are not immediate family members; and for individuals being admitted or in a nursing home or hospital—adding in the “explainer” witness signature). California’s PREPARE for Your Care form has more translations available - scroll to the bottom of this list for the link to their website.

Appointment of a a Health Care Agent Form (Arabic)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Arabic)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Bosnian)

Includes VADR Registration Agreement & Authorization to Change form

Download Form

Advance Directive Short Form (Bosnian)

Includes VADR Registration Agreement & Authorization to Change form

Download Form

Appointment of a Health Care Agent Form (Burmese)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Burmese)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Chinese)

Includes VADR Registration Agreement & Authorization to Change form

Download Form

Advance Directive Short Form (Chinese)

Includes VADR Registration Agreement & Authorization to Change form

Download Form

Appointment of a Health Care Agent Form (Farsi)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Farsi)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (French)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (French)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Kirundi)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Kirundi)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Nepali)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Nepali)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Somali)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Somali)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Spanish)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Spanish)

Includes VADR Registration Agreement & Authorization to Change form

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Appointment of a Health Care Agent Form (Swahili)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Swahili)

Includes VADR Registration Agreement & Authorization to Change form

Download Form

Appointment of a Health Care Agent Form (Vietnamese)

Includes VADR Registration Agreement & Authorization to Change form

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Advance Directive Short Form (Vietnamese)

Includes VADR Registration Agreement & Authorization to Change form

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California's PREPARE for Your Care Forms

Use the link below to visit PREPARE for Your Care's website.

Visit PREPARE for Your Care