Letter of Instruction in Case of Emergency

Created by
Your Name
Email
Date / Time of Completion
Name of Primary Emergency Contact
Name of person authorized to speak and act on your behalf in the event of emergency or death.
Name of Back-up Emergency Contact
Name of person authorized to speak and act on your behalf in the event primary emergency contact is unavailable or unable to assist.

Medical Authorizations

Medical Power of Attorney / Designated Healthcare Proxy
Name of person authorized to make medical decisions on your behalf.
Provide location of the signed original document.
Primary Care Provider
DNR Status
Organ Donor

Legal Authorizations & Original Documents Location

Legal Power of Attorney
Provide location of signed original document.

Primary Financial Information & Location of Cash on Hand

Name, location, and telephone of primary bank used for checking or savings and account numbers.

Digital & Online Presence Management

Digital Executor
Name of person who will manage your online presence on social media, online subscription services, and related activity.
Email

Emergency Custodial Caretaker of Minor Children and Pets

Name
Name of person authorized to take temporary custody of your minor children.
Address
Emergency Pet Caretaker
Person authorized to take custody of your pets.
Address
Name and Contact Info – Veterinarian along with any special care instructions.

End-of-Life and Final Arrangements

End-of-Life Doula
My EOL Doula is to be alerted and kept informed of all emergent situations and changes in my health and well-being status, including notification of my death.
Address
Hospice Agency Coordinator
In-Home Caregiver
Provide end-of-life Doula and In-home caregiver contact information.

Key Others to Notify

1. Pastor / Minister / Chaplain
2. Employer
3. Name
List specific final arrangements regarding care at end-of-life, such as: cremation, green burial, closed casket, along with location of any additional detailed information regarding my choices for final arrangements.
Clear Signature
Please provide your signature once printed.

PRIVACY & SECURITY NOTICE

This document contains sensitive personal and financial information. It is intended solely for the use of your designated representatives in the event of an emergency. Do not store this document in an unsecure location or share it digitally over unencrypted email. We recommend keeping a physical copy in a fireproof safe or a locked file cabinet and ensuring your trusted agent knows how to access it.

Disclaimer: This Letter of Instruction is a personal guide provided by Soul at Heart Doula Services and does not replace a legally binding Will or Power of Attorney. Please consult with a legal professional to ensure your estate plan is fully executed according to state law.

This form is provided for your convenience by Soul at Heart Doula.

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