Wyoming Statutes Title 35. Public Health and Safety § 35-22-303. Psychiatric advance directive forms; duties of department of health

(i) The person's name, date of birth and sex;

(ii) The person's eye and hair color;

(iii) The person's race or ethnic background;

(iv) The person's social security number;

(v) If applicable, the name of a treatment program and the sponsoring facility or institution in which the person is enrolled;

(vi) The name, address and telephone number of the person's attending physician or psychiatric personnel;

(vii) The person's signature or mark or, if applicable, the signature of a person authorized by this article to execute a psychiatric advance directive;

(viii) The date on which the psychiatric advance directive was signed;

(ix) The person's directive concerning the administration or refusal of psychiatric restabilization measures, countersigned by the person's attending physician or psychiatric personnel;

(x) The name, address and telephone number of the person designated as an agent, if applicable, to consent to or refuse psychiatric restabilization measures for the person who has executed a psychiatric advance directive and the signature of that person, indicating acceptance of this appointment.