1997 Florida Code
TITLE XLIV CIVIL RIGHTS
Chapter 765 Health Care Advance Directives  
PART II HEALTH CARE SURROGATE (ss. 765.201-765.205)
765.203   Suggested form of designation.

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.