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2013 Florida Statutes

F.S. 765.203
765.203 Suggested form of designation.A written designation of a health care surrogate executed pursuant to this chapter may, but need not be, in the following form:

DESIGNATION OF HEALTH CARE SURROGATE

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: 

      Zip Code:  

Phone:    

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

Name: 

Address: 

      Zip Code:  

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; 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.

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. 
History.s. 3, ch. 92-199; s. 1145, ch. 97-102; s. 9, ch. 2000-295; s. 1, ch. 2008-223.