Living Will, Designation Of Health Care Surrogate, Uniform Donor Forms Page 2
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3Designation of Health Care Surrogate
Name: ______________________________________________________
In the event that 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_________ 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_________ 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 _____________________________________________________
Date _________________________
Witnesses
1. ________________________________________
2. ________________________________________
At least one witness must not be a husband or wife or a blood relative of the principal.
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