Designation of health care surrogate for a minor; suggested form.

A written designation of a health care surrogate for a minor executed pursuant to this chapter may, but need not, be in the following form:

DESIGNATION OF HEALTH CARE SURROGATE

FOR MINOR

I/We, (name/names) , the [ ________ ] natural guardian(s) as defined in s. 744.301(1), Florida Statutes; [ ________ ] legal custodian(s); [ ________ ] legal guardian(s) [check one] of the following minor(s):

________ ________ ________ ________ ________ ________ ________ ;

________ ________ ________ ________ ________ ________ ________ ;

________ ________ ________ ________ ________ ________ ________ ,

pursuant to s. 765.2035, Florida Statutes, designate the following person to act as my/our surrogate for health care decisions for such minor(s) in the event that I/we am/are not able or reasonably available to provide consent for medical treatment and surgical and diagnostic procedures:

Name: (name)

Address: (address)

Zip Code: (zip code)

Phone: (telephone)

If my/our designated health care surrogate for a minor is not willing, able, or reasonably available to perform his or her duties, I/we designate the following person as my/our alternate health care surrogate for a minor:

Name: (name)

Address: (address)

Zip Code: (zip code)

Phone: (telephone)

I/We authorize and request all physicians, hospitals, or other providers of medical services to follow the instructions of my/our surrogate or alternate surrogate, as the case may be, at any time and under any circumstances whatsoever, with regard to medical treatment and surgical and diagnostic procedures for a minor, provided the medical care and treatment of any minor is on the advice of a licensed physician.

I/We fully understand that this designation will permit my/our designee to make health care decisions for a minor and to provide, withhold, or withdraw consent on my/our behalf, to apply for public benefits to defray the cost of health care, and to authorize the admission or transfer of a minor to or from a health care facility.

I/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate:

Name: (name)

Name: (name)

Signed: (signature)

Date: (date)

WITNESSES:

1. (witness)

2. (witness)