The health care proxy shall:

1. (i) identify the principal and the health care agent;
2. (ii) indicate that the principal intends the agent to have authority to make health care decisions on the principal's behalf;
3. (iii) describe the limitation, if any, that the principal intends to impose upon the agent's authority; and
4. (iv) indicate that the agent's authority shall become effective if it is determined pursuant to section six that the principal lacks capacity to make health care decisions.