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, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to
law, 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. ________________________________
