LPA Health & Welfare Questionnaire |

First Name(s) *

Surname *

Date of Birth *

Address *

Email *

Contact Number *

How many attorneys do you wish to appoint? *

Attorney Details * Please provide title, full name, date of birth and address of attorney(s)

If you have listed more than one attorney, how do you want them to work together? *

Would you like any replacement attorneys? *

Replacement Attorney details If yes, please provide title, full name, date of birth and address for each replacement attorney.

Do you want the attorneys to make decisions about life sustaining treatment? *

Witness Signatures * Who do you select as your witness for the signatures? Please ensure this is someone who is not a family member, is an independent person and not one of the attorneys. Please provide title, full name and address for witness.

Certificate Provider * Who do you select as your certificate provider? This should be someone who is not a family member in any way, is an independent person, has known you for at least 2 years and is not one of the attorneys. It can also be a professional such as your GP or a solicitor. Please provide title, full name and address for certificate provider.

AL-HQ Law & More is a company registered in England and Wales with Companies House under registration number 13148335. We are a specialist international legal practice holding membership with the Society of Will Writers (SWW) and the Best Foundation. We provide a social enterprise network of lawyers, solicitors and educators through a consultancy model. Our in-house solicitors are regulated by the Solicitors Regulation Authority (SRA). Our in-house educators are registered with the Society of Legal Scholars (SLS) and the Society of Trust and Estate Practitioners (STEP).

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