Designation Of Health Care Surrogate Template
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3Designation of Health Care Surrogate
Name:
In the event that I (Principal) 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
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.
Principal’s Signature
Surrogate’s Signature
Date
Notary Acknowledgement
State of
County of
Subscribed, Sworn and
acknowledged before me by
, the Principal, and
subscribed and sworn to before me by
, witness, this
day of
.
Notary Signature
Notary Public
In and for the County of
State of
Seal
My commission expires:
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