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:

{c1} {c2}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: {c1} {c2}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: {c1}Witnesses: {c2}1. {c1}{c2}2. History.--s. 3, ch. 92-199; s. 1145, ch. 97-102. Home Senators Senator List Find Your Legislators District Maps Vote Disclosures Committees Committee List Committee Publications Search Bill Search Tips Statute Search Tips Site Search Tips Session Bills Calendars Journals Appropriations Conferences Reports Executive Appointments Executive Suspensions Redistricting Laws Statutes Constitution Laws of Florida Order - Legistore Media Publications Videos Topics Video Broadcast Schedule About Employment Visit Us Contact Us Page Program Offices President's Office Majority Office Minority Office Secretary's Office Reference Glossary FAQ Help Links Search Tips Publications Rules Handbooks Advisory Opinions Public Records Connect with the Senate Twitter RSS Senate Tracker Login Sign Up Tracker Help Plug-ins Adobe Acrobat Reader WinZip Disclaimer: The information on this system is unverified. The journals or printed bills of the respective chambers should be consulted for official purposes. Privacy Statement|Accessibility Copyright © 2000- 2026 State of Florida.