Blue Ridge Cardiology & Internal Medicine
Advanced Directive Notification Form
If yes please list name and contact information below
I have talked with my family and my doctor about the care I want. If I am unable to speak for myself, please contact:
(Name) (Phone #) (Relationship to Patient)<br/>
(Name) (Phone #) (Relationship to Patient)
(Name) (Phone #) (Relationship to Patient)
Electronic Signature
Date of Birth
