(1) Identify the principal and appoint the health care agent.

(2) Declare that the principal authorizes the health care agent to make health care decisions on behalf of the principal.

(1) Describe any limitations that the principal imposes upon the authority of the health care agent.

(2) Indicate the intent of the principal regarding the initiation, continuation, withholding or withdrawal of life-sustaining treatment.

(3) Indicate whether the principal wants tube feeding or any other artificial or invasive form of nutrition or hydration.

(4) Disqualify an individual from acting as a health care representative, prohibit the appointment of a health care representative or provide for an order of priority of appointment of a health care representative pursuant to section 5461(d) (relating to decisions by health care representative).

(5) Nominate a guardian of the person of the principal as provided in section 5460 (relating to relation of health care agent to court-appointed guardian and other agents).

(6) Contain other provisions as the principal may specify regarding the implementation of health care decisions and related actions by the health care agent or health care representative.

(7) Request that the health care agent or health care representative exercise his sole and absolute discretion to consult the principal's relative, cleric or physician should the health care agent or health care representative be uncertain of the principal's wishes or best interests.