Trusted companion
designation form

Official form, to be kept and given to your doctor or healthcare facility

Art. L1111-6 of the French
Public Health Code
Claeys-Leonetti Act
2 February 2016

Reminder: Any adult may designate a trusted companion. This can be a relative, a loved one, or the treating physician. The designation is made in writing, co-signed by the designated person, and can be cancelled at any time.

Reference translation: This English version is provided for understanding only. Under French law, only the French original is the legally valid document to sign and submit to a French doctor or healthcare facility.

I, the undersigned · The patient

Last name

First name

Date of birth

Address

Phone

Email (optional)

Designates as trusted companion

Last name

First name

Address

Phone

Relationship to patient

Duties entrusted

Accompany me during medical consultations, examinations and hospitalisations Be consulted if I am unable to express my wishes, in order to convey them Receive the information necessary to support me in my decision-making Represent my interests to medical teams and institutions Assist me with administrative matters related to my care

Duration of the designation

For an indefinite period (revocable in writing at any time) For the duration of the following hospitalisation or care episode:

Signatures

The patient · Name, date and signature

Done at

Sign here (mouse or finger)

The trusted companion · Name, date and signature

Done at

Sign here (mouse or finger)

Provide in two copies: one copy kept by the patient, one copy given to the trusted companion. It is also recommended to give a copy to your treating physician and/or the relevant healthcare facility.

— Revocation coupon —

I, the undersigned, revoke the previously established trusted companion designation.

Patient's last name

First name

Last name of the person revoked

First name

Patient's signature · Date

Done at

Sign here (mouse or finger)

Trusted companiondesignation form

Trusted companion
designation form