(Date)..................................
I, ..............................., (patient who is designating another person as having visitation rights of the patient) do hereby designate .................................. (person who is being designated as having visitation rights of the patient) as having the right to visit me in a medical facility or facility for the dependent. I hereby instruct all staff of a medical facility or facility for the dependent in which I am a patient to admit ...................................... (person who is being designated as having visitation rights of the patient) to my room and afford him or her the same visitation rights as are provided to members of my family who are legally related to me during my time as a patient.
........................................................
(Signed)
NRS 449A.109