Designation of Health Care Surrogate of

DAUGHTER’S NAME
In accordance with Section 765.203, Florida Statutes
In the event I, DAUGHTER’S NAME, 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:

PERSON 1 NAME (Mother) – (407) 000-0000

100 Road Dr.
Land O Lakes, FL 34639

If my surrogate is unwilling or unable to perform her duties, I wish to designate as my alternate surrogate(s):

PERSON 2 NAME (Grandmother) – (321) 000-0000

100 Road Dr.
Land O Lakes, FL 34639

ADDITIONAL INSTRUCTIONS: __________________________________________________________________

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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 or apply for public benefits to defray the cost of health
care and to authorize my admission to or transfer from a health care facility. I permit my health care
surrogate complete access to all medical records and protected health information, and I further
permit my surrogate to authorize or petition for long-term inpatient care when required. I further
affirm that this designation is not being made as a condition of treatment or admission to a health care
facility and may be revoked at any time during which I have capacity.

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DAUGHTER’S PRINTED NAME, Signature Date

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Witness One Signature Witness Two Signature

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Printed Name & Address of Witness One Printed Name and Address of Witness Two