Designation of Health Care Surrogate 
Name: ______________________________________________________________

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: __________________________
Phone: ________________________________
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate: 
Name: ______________________________________________________________
Address: _____________________City/State_______________Zip: _______
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: _____________________
Witness 1: _________________________________________________________
Witness 2: _________________________________________________________

Florida Statute 765.203