Designation of Health Care Surrogate, Florida

FLORIDA DESIGNATION OF HEALTH CARE SURROGATE

Title XLIV, Chapter 765 (Section 765.203)

Name:  ____________ (Last)  _______________(First) ____ (Middle Initial)

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:                       ________________________________

Address:                   ________________________________

                                  ________________________________

Phone:                      ________________________________

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:

Name:                      ________________________________

Address:                   ________________________________

                                 ________________________________

Phone:                     ________________________________

I fully understand that this designation will permit my designee to make health care decisions, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law (Uniform Donor Form), and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility.