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Form #710Designation of Health Care Surrogate
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Florida - Designation of Health Care Surrogate (free form to use)
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Florida.
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
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. ...........................................................................................................................................................................................................
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state. Also, agreements should relate specifically to the particular facts of each
situation. Therefore, it is important to consult legal counsel whenever utilizing
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Keywords: Florida, Health Care Surrogate, will, wills, legal forms
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