Medical Power of Attorney.json

{
    "pc": {
        "type": "Grid",
        "model": {
            "stacked": "md",
            "frame": {
                "horizontal": null,
                "vertical": null,
                "radius": null
            },
            "border": {
                "width": null,
                "color": null
            },
            "rows": [{
                "cells": [{
                    "component": {
                        "type": "Stack",
                        "model": {
                            "_internalName": "Stack1",
                            "fill": "None",
                            "overflow": "wrap",
                            "cells": [{
                                "component": {
                                    "type": "Image",
                                    "model": {
                                        "_internalName": "Image1",
                                        "height": 70,
                                        "target": "_blank",
                                        "image": "https://plumsail.com/assets/forms/templates/medical-questionnaire-form-2-image-01.png"
                                    }
                                },
                                "alignment": {
                                    "vertical": "Middle",
                                    "horizontal": null
                                }
                            }, {
                                "component": {
                                    "type": "Heading",
                                    "model": {
                                        "_internalName": "Heading1",
                                        "heading": "Medical Power of Attorney",
                                        "view": "Normal",
                                        "font": {
                                            "style": "Normal",
                                            "weight": "Semibold"
                                        },
                                        "frame": {
                                            "horizontal": 20,
                                            "vertical": null,
                                            "radius": null
                                        },
                                        "size": "H1",
                                        "textAlignment": "Left"
                                    }
                                },
                                "alignment": {
                                    "vertical": "Middle",
                                    "horizontal": null
                                }
                            }]
                        }
                    },
                    "alignment": {
                        "horizontal": "Left",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "TabControl",
                        "model": {
                            "_internalName": "Tabs1",
                            "orientation": "Top",
                            "pills": false,
                            "wrap": true,
                            "border": {
                                "width": 2,
                                "color": "#424242"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": 10,
                                "radius": null
                            },
                            "font": {
                                "style": "Normal",
                                "weight": "Bold"
                            },
                            "tabs": [{
                                "_internalName": "Tab2",
                                "title": "Principal",
                                "component": {
                                    "type": "Grid",
                                    "model": {
                                        "stacked": "md",
                                        "frame": {
                                            "horizontal": null,
                                            "vertical": null,
                                            "radius": null
                                        },
                                        "border": {
                                            "width": null,
                                            "color": null
                                        },
                                        "rows": [{
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalFullName",
                                                        "title": {
                                                            "text": "Full Name",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalStreetAddress1",
                                                        "description": "Street Address line 1",
                                                        "title": {
                                                            "text": "Address",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalStreetAddress2",
                                                        "description": "Street Address line 2",
                                                        "title": {
                                                            "text": "Address",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalCity",
                                                        "description": "City",
                                                        "title": {
                                                            "text": "City",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalState",
                                                        "description": "State / Province",
                                                        "title": {
                                                            "text": "State",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalZIP",
                                                        "description": "ZIP",
                                                        "title": {
                                                            "text": "ZIP",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalCountry",
                                                        "description": "Country",
                                                        "title": {
                                                            "text": "Country",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "PrincipalEmail",
                                                        "title": {
                                                            "text": "Email",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cHint": "username@domain.com",
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "E-mail",
                                                        "pattern": "^[^@\\s]+@[^@\\s]+\\.[^@\\s]+$",
                                                        "error": "This field must contain a valid e-mail address."
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "MaskedInput",
                                                    "model": {
                                                        "_internalName": "PrincipalPhone",
                                                        "title": {
                                                            "text": "Phone",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "mask": "000-000-0000"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }]
                                    }
                                }
                            }, {
                                "_internalName": "Tab3",
                                "title": "Agents",
                                "component": {
                                    "type": "Grid",
                                    "model": {
                                        "stacked": "md",
                                        "frame": {
                                            "horizontal": null,
                                            "vertical": null,
                                            "radius": null
                                        },
                                        "border": {
                                            "width": null,
                                            "color": null
                                        },
                                        "rows": [{
                                            "cells": [{
                                                "component": {
                                                    "type": "Heading",
                                                    "model": {
                                                        "_internalName": "Heading2",
                                                        "heading": "Primary Agent",
                                                        "view": "Normal",
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "frame": {
                                                            "horizontal": null,
                                                            "vertical": null,
                                                            "radius": null
                                                        },
                                                        "size": "H3",
                                                        "textAlignment": "Left"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentFullName",
                                                        "title": {
                                                            "text": "Full Name",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentStreetAddress1",
                                                        "description": "Street Address line 1",
                                                        "title": {
                                                            "text": "Address",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentStreetAddress2",
                                                        "description": "Street Address line 2",
                                                        "title": {
                                                            "text": "Address",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentCity",
                                                        "description": "City",
                                                        "title": {
                                                            "text": "City",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentState",
                                                        "description": "State / Province",
                                                        "title": {
                                                            "text": "State",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentZIP",
                                                        "description": "ZIP",
                                                        "title": {
                                                            "text": "ZIP",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentCountry",
                                                        "description": "Country",
                                                        "title": {
                                                            "text": "Country",
                                                            "visible": false
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "Anything"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "SingleLineText",
                                                    "model": {
                                                        "_internalName": "AgentEmail",
                                                        "title": {
                                                            "text": "Email",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cHint": "username@domain.com",
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "type": "E-mail",
                                                        "pattern": "^[^@\\s]+@[^@\\s]+\\.[^@\\s]+$",
                                                        "error": "This field must contain a valid e-mail address."
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "MaskedInput",
                                                    "model": {
                                                        "_internalName": "AgentPhone",
                                                        "title": {
                                                            "text": "Phone",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "mask": "000-000-0000"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "Heading",
                                                    "model": {
                                                        "_internalName": "Heading3",
                                                        "heading": " Alternate Agent(s)",
                                                        "view": "Normal",
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "frame": {
                                                            "horizontal": null,
                                                            "vertical": null,
                                                            "radius": null
                                                        },
                                                        "size": "H3",
                                                        "textAlignment": "Left"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "DataTable",
                                                    "model": {
                                                        "_internalName": "AlternateAgent",
                                                        "title": {
                                                            "text": "If my agent appointed above is unable or unwilling to serve as my agent, I appoint the following person(s) to serve as agents in the order set forth below with the authority to make health care decisions on my behalf as provided herein:",
                                                            "visible": true
                                                        },
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "newLine": "Top",
                                                        "delete": "Last",
                                                        "columns": [{
                                                            "_internalName": "FullName",
                                                            "title": "Full Name",
                                                            "required": false,
                                                            "type": "String",
                                                            "aggregates": [{
                                                                "type": "count",
                                                                "template": "Count: {0}"
                                                            }]
                                                        }, {
                                                            "_internalName": "Address",
                                                            "title": "Address",
                                                            "required": false,
                                                            "type": "String",
                                                            "aggregates": []
                                                        }, {
                                                            "_internalName": "Phone",
                                                            "title": "Phone",
                                                            "required": false,
                                                            "type": "MaskedText",
                                                            "aggregates": [],
                                                            "mask": "000-000-0000"
                                                        }, {
                                                            "_internalName": "Email",
                                                            "title": "Email",
                                                            "required": false,
                                                            "type": "String",
                                                            "aggregates": []
                                                        }]
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }]
                                    }
                                }
                            }, {
                                "_internalName": "Tab5",
                                "title": "Limitations",
                                "component": {
                                    "type": "Grid",
                                    "model": {
                                        "stacked": "md",
                                        "frame": {
                                            "horizontal": null,
                                            "vertical": null,
                                            "radius": null
                                        },
                                        "border": {
                                            "width": null,
                                            "color": null
                                        },
                                        "rows": [{
                                            "cells": [{
                                                "component": {
                                                    "type": "MultiLineText",
                                                    "model": {
                                                        "_internalName": "Limitations",
                                                        "title": {
                                                            "text": "Limitations on My Agent",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "mode": "Plain"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "MultipleChoice",
                                                    "model": {
                                                        "_internalName": "organsAny",
                                                        "title": {
                                                            "text": "Organ Donation",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        },
                                                        "dataSource": "StaticList",
                                                        "cColumns": 1,
                                                        "options": [{
                                                            "value": "Donate any needed organs or parts",
                                                            "backgroundColor": null,
                                                            "textColor": null
                                                        }, {
                                                            "value": "Donate my body for anatomical study",
                                                            "backgroundColor": null,
                                                            "textColor": null
                                                        }, {
                                                            "value": "Do not donate organs or body parts",
                                                            "backgroundColor": null,
                                                            "textColor": null
                                                        }],
                                                        "allowUserValue": false,
                                                        "defaultValue": []
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }]
                                    }
                                }
                            }, {
                                "_internalName": "Tab1",
                                "title": "Signatures",
                                "component": {
                                    "type": "Grid",
                                    "model": {
                                        "stacked": "md",
                                        "frame": {
                                            "horizontal": null,
                                            "vertical": null,
                                            "radius": null
                                        },
                                        "border": {
                                            "width": null,
                                            "color": null
                                        },
                                        "rows": [{
                                            "cells": [{
                                                "component": {
                                                    "type": "Text",
                                                    "model": {
                                                        "_internalName": "Text1",
                                                        "text": "I understand that this power of attorney exists indefinitely from the date I execute this document\nunless I establish a shorter time or revoke the power of attorney. If I am unable to make health care\ndecisions for myself when this power of attorney expires, the authority I have granted my agent\ncontinues to exist until the time I become able to make health care decisions for myself."
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "Date",
                                                    "model": {
                                                        "_internalName": "TerminationDate",
                                                        "title": {
                                                            "text": "This power of attorney ends on the following date (optional):",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cFont": {
                                                            "style": "Normal",
                                                            "weight": "Normal"
                                                        }
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "Text",
                                                    "model": {
                                                        "_internalName": "Text2",
                                                        "text": "By signing this document, I hereby revoke any and all prior medical powers of attorney that I may\nhave executed."
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Justify",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 12
                                                }
                                            }]
                                        }, {
                                            "cells": [{
                                                "component": {
                                                    "type": "Signature",
                                                    "model": {
                                                        "_internalName": "PrincipalSignature",
                                                        "title": {
                                                            "text": "Principal Signature",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cWidth": 300,
                                                        "height": 150,
                                                        "inkColor": "#000000"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Center",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }, {
                                                "component": {
                                                    "type": "Signature",
                                                    "model": {
                                                        "_internalName": "Agent Signature",
                                                        "title": {
                                                            "text": "Agent Signature",
                                                            "visible": true
                                                        },
                                                        "orientation": "Vertical",
                                                        "required": false,
                                                        "font": {
                                                            "style": "Normal",
                                                            "weight": "Semibold"
                                                        },
                                                        "wrap": true,
                                                        "cWidth": 300,
                                                        "height": 150,
                                                        "inkColor": "#000000"
                                                    }
                                                },
                                                "alignment": {
                                                    "horizontal": "Center",
                                                    "vertical": "Top"
                                                },
                                                "columns": {
                                                    "width": 6
                                                }
                                            }]
                                        }]
                                    }
                                }
                            }]
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Submit",
                        "model": {
                            "_internalName": "Submit1",
                            "text": "Submit",
                            "savingText": "Submitting...",
                            "type": "Primary",
                            "click": "return fd.save();"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }]
        }
    },
    "tablet": null,
    "phone": null,
    "js": "",
    "css": "",
    "notifySubscribers": false,
    "version": "1.0.2",
    "theme": {
        "primary": "#795548",
        "bodyText": "#262626",
        "bodyBackground": "#FAFAFA",
        "fontFamily": "Nunito Sans",
        "fontType": 1,
        "fontSize": 18,
        "fontWeight": 400,
        "borderThickness": 2,
        "borderRadius": 1,
        "shadow": true,
        "themeId": "aa6c56b2b45277cc1ef307c88fb89900",
        "isDark": false
    },
    "timezone": "America/Glace_Bay",
    "culture": "en",
    "userLanguage": "",
    "userCulture": "",
    "thankYouMessage": null,
    "redirectURL": null,
    "hideAfterSubmission": false,
    "submissionTimeout": 0,
    "authentication": 0,
    "singleSubmissionPerUser": false,
    "allowEditingSubmission": false,
    "restrictAccess": false,
    "azureADTenant": null,
    "azureADObjects": [],
    "azureB2CProperties": null,
    "connection": null
}