Florida Designation Of Health Care Surrogate
[PRINT YOUR NAME]
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:
[PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR SURROGATE]
Name: ... 
Address: ... 
... Zip Code: _______
Phone: ... 
If my surrogate is unwilling or unable to perform his duties, I wish to designate as my alternate surrogate:
[PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATIVE 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.
[ADD PERSONAL INSTRUCTIONS (IF ANY)]
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:
[PRINT THE NAMES AND ADDRESSES OF THOSE WHO YOU WANT TO KEEP COPIES OF THIS DOCUMENT]
Name: ... 
Address: ... 
Name: ... 
Address: ... 
[SIGN AND DATE THE DOCUMENT]
Signed: ... 
Date: ... 
[TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES]
Witness #1:

Signed: ... 
Address: ... 
Witness #2:

Signed: ... 
Address: ...