Beacon Legacy Group Simple Online Wills and Power of Attorneys

Registration Info

Provide your details below to get started on your online questionnaire.

First Name *

Middle Name

Last Name *

Email *

Password *

Cell *

Young Adult Info

Are you a parent filling this out for your college student? *

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Yes

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No

Student Name

Your Contact Details

Name:

Date Of Birth *

Also known as(optional)

Are you married? *

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Yes

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No

Suffix(optional)

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Jr

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Sr

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II

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III

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Other

What are your personal pronouns?

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he/him

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she/her

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they/them

Your Address

Full Address: *

Address Line 1 *

Address Line 2

City *

State *

County *

Zip Code *

Is Your mailing address the same as your home address? *

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Yes

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No

Financial DPOA:

Provide the information of one or more individuals who will serve as your agent under the Durable Power of Attorney:

Do you want your Primary Agent’s powers to be effective immediately upon signing or only when you are incapacitated? *

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Immediate

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Incapacity Only

Primary Agent: *

Phone Number *

Address *

Health Care POA

Name someone (agents) to make medical decisions on your behalf in the event that you are unable to make those decisions for yourself

Please provide the information of one or more individuals who will serve as your health care agent:

Do you wish to use the same agents as your Financial Durable POA? *

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Yes

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No

Primary Agent: *

Phone Number *

Address *

Health Care POA - Spouse/Partner

Name someone (agents) to make medical decisions on your behalf in the event that you are unable to make those decisions for yourself.

Please provide the information of one or more individuals who will serve as your health care agent:

Do you wish to use the same agents as your Power of Attorney? *

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Yes

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No

Primary Agent: * Click the "+" button to add another individual.

Phone Number *

Address *

Would you like to be an organ donor? *

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Yes﹐for transplantation purposes only

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Yes﹐for transplantation﹐education and/or research

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No

Advance Health Care Directive Agent

Your Advance Health Care Directive Agent will make medical decisions for you if you are incapacitated or otherwise unable to do so yourself. When picking an Advance Health Care Directive Agent, pick someone who would be comfortable serving in this role. Also, consider whether that person would have similar ideas as you regarding medical care.

Please provide the information of one or more individuals who will serve as your advance health care agent:

Do you wish to use the same agents as your Health Care POA? *

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Yes

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No

Agent Name: * Click the "+" button to add another individual.

Relation *

Home Phone *

Mobile Phone

Address *

Advance Health Care Directive Agent (Spouse)

Your Advance Health Care Directive Agent will make medical decisions for you if you are incapacitated or otherwise unable to do so yourself. When picking an Advance Health Care Directive Agent, pick someone who would be comfortable serving in this role. Also, consider whether that person would have similar ideas as you regarding medical care.

Please provide the information of one or more individuals who will serve as your advance health care agent:

Do you wish to use the same agents as your Health Care POA? *

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Yes

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No

Agent Name: * Click the "+" button to add another individual.

Relation *

Home Phone *

Mobile Phone

Address *

Indicate Your Wishes for Quality of Life

By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an unacceptable quality of life).

Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma. *

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Yes

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No

Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or cannot have a clear conversation with them. *

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Yes

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No

Dependent in all Activities of Daily Living: I am no longer able to talk or communicate clearly or move by myself. I depend on others for feeding, bathing, dressing, and walking. Rehabilitation or any other restorative treatment will not help. *

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Yes

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No

End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples: Widespread cancer that no longer responds to treatment; chronic and/or damaged heart and lungs, where oxygen is needed most of the time and activities are limited due to the feeling of suffocation. *

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Yes

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No

Indicate Your Wishes for Treatment

CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance. *

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Yes

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No

Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys, and other organs to continue to work. *

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Yes

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No

Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will not help the main illness. *

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Yes

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No

Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which would include artificially delivered nutrition and hydration. *

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Yes

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No

Other Instructions

Other instructions, such as hospice care, burial arrangements, etc.:

Please write below any other instructions you would like for us to include in your document. Here is a sample of language commonly requested and added by clients. If you like this language, please feel free to copy and paste it below with any other instructions you may have, if any:

“I want adequate comfort care and pain management to be administered during my lifetime. If I should need a conservator, I wish it to be the same individuals I have listed under Health Care Agents. I want my Health Care Agent to have custody of my body upon my death. If I should need Hospice care, I would like to have Hospice care. If my Health Care Power of Attorney and this Tennessee Advance Directive for Health Care should ever conflict, I would like my Health Care Power of Attorney to prevail.”

Organ donation: Upon my death, I wish to make the following anatomical gift for purposes of transplantation, research, and/or education (mark one): *

Any Organ/tissue My entire body No Organ/tissue donation Only the following organs/tissues

Submission Screen

If you would like to edit or review your responses, you can select each screen on the right or bottom, you can select each screen and review your answer or select the previous button which will open a print screen page. Click the “Submit” button below to be directed to a page where you will be able to pay for your estate planning documents you selected. Once you have paid for your documents, your information will be sent to our office, and you will then be prompted to schedule a phone call or Zoom meeting to review your documents.

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