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:
Phone:
If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:
Name:
Address:
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:
