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.