Checklist For Surrogate Selection Form (Page 4 of 4) in pdf

Checklist For Surrogate Selection Form Page 4

Patient Name ____________________________________________ Hospital # _______________________

Name

Date

Time

Contacted by

12. If a family member / close friend who was not selected disagrees with the surrogate chosen, tell

him or her it is his / her responsibility to:

a. Notify the attending physician in writing. ____ (Initial when done)

b. Go to court to challenge the selection of the surrogate. ____ (Initial when done)

13. Did any potential surrogate object? Yes ____ No ____

If yes, enter name and basis for objection: ____________________________________________

______________________________________________________________________________

14. Notify the person who objects that he / she has 72 hours to get a court order.

Date ______________________ and time ___________________________ notified.

I HAVE COMPLETED OR REVIEWED THIS FORM AND MADE THE DECISION TO APPOINT

_____________________________________________________________ AS SURROGATE WHO

CAN BE REACHED AT PHONE NUMBER(S)

_______________ (home)

______________ (work)

____________ (cell phone)

__________________________________________________________________________________

Physician Signature / Date / Time

__________________________________________________________________________________

Signature of person assisting the physician in completing this form (if any).

Acceptance of Surrogate Selection

I accept the appointment as surrogate for _______________________________________________ and

understand I have the authority to make all medical decisions for ________________________________.

_______________________________________

Signature of Surrogate

Checklist For Surrogate Selection Form Page 4