# Do Not Borg Form
[color=#5b97bc]█▄ █ ▀█▀    [head=2]DO NOT BORG[/head]
█ ▀█     █        [color=red]This document invalid unless stamped[/color][/color]
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[color=red][bold]This document is intended to allow individuals who would not like to be made into a cyborg when they die to advocate as such. It is not intended to be used by others to prevent the borgification of another individual unless they are an approved health-care surrogate of the patient or court-appointed guardian of the patient.[/bold][/color]

Patients Name:   [color=#002AAF]Sample Person[/color]
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[head=1]PATIENTS STATEMENT[/head]
Based upon informed consent, I, the undersigned, hereby direct that cyborgification be withheld or withdrawn.
[bold](If not signed by patient, check applicable box)[/bold]
\[  ] Surrogate    \[  ] Court-Appointed Guardian

Applicable Signature:   [color=#002AAF]Sample Signature[/color]
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[head=2]CMO READ BELOW[/head]
In order for this form to be valid it MUST be stamped by the Chief Medical Officer of the station/ship/colony.
[bold]BY STAMPING BELOW, YOU HEREBY CERTIFY:
1. You have informed the patient/surrogate/guardian of the implications of this order.
2. You witnessed the signing of the document by the patient/surrogate/guardian.
3. You vouch for the authenticity of the signature and document.[/bold]

[italic]               When complete, please stamp in the area below