Designation Form Of Health Care Surrogate, Living Wills And Health Care Advance Directives: Faqs

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Suggested form of a Health Care Surrogate, Florida Statutes Section 765.203
Designation of Health Care Surrogate
Name
In the event I have been determined to be incapacitated to provide informed consent for medical treatment and
surgical and diagnostic procedures, I wish to designate, as my surrogate for health care decisions:
Name
Street Address
City
State
Zip
Phone
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:
Name
Street Address
City
State
Zip
Phone
I fully understand that this designation will permit my designee to make health care decisions and to provide,
withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of health care; and to
authorize my admission to or transfer from a health care facility
Additional Instructions (optional):
I further affirm that this designation is not being made as a condition of treatment or admission to a health care
facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they
may know who my surrogate is.
Name
Name
Signed:
Witnesses
1.
2.
At least one witness must not be a husband or wife or a blood relative of the principal.
— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —
02/04

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