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STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS In exercising authority under this document, my health care agent shall act consistently with my followin .tated desires,

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STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS In exercising authority under this document, my health care agent shall act consistently with my followin .tated desires, if any, and is subject to any special provisions or limitations that I specify' The following are an .pecic desires, provisions or limitations that I wish to state (add more items if needed): 1. 2

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