Main Menu | World Index | USA | Australia | Canada | España | Germany | Israel | Japan | UK
Academic: Law Journals | Law Outlines | Law Schools | Law Students | Legal Study Abroad | Pre-Law | Rankings
Profession: Associations | CLE | Corporations | Experts | Legal Forms | Legal Topics | Lawyers/Firms | NLJ250
Other: Bookstore | News | Web Indices | U.S. Statutes | U.S. Caselaw |
Search Site | Submit URL | Non-Legal



Support The Internet Legal Research Group; Visit Our Advertisers


NOTE: THE FORMS AVAILABLE IN THIS ARCHIVE ARE SUBJECT TO OUR TERMS OF USE AND ARE NOT A SUBSTITUTE FOR THE ADVICE OF AN ATTORNEY. LEGAL ADVICE OF ANY NATURE SHOULD BE SOUGHT FROM COMPETENT LEGAL COUNSEL IN THE RELEVANT JURISDICTION. THESE FORMS ARE PROVIDED "AS IS."
Main Menu > Legal Forms Archive
Email Me This Form!  Do you want a copy of this form emailed to you as a Word document? Read more.
Fax Me This Form!  Do you want a copy of this form faxed to you? Read more. Sixty nations serviced!
Questions: Question about this form? Ask us, and we'll endeavor to post an answer as soon as possible.
Quality: We're committed to quality. Have you found a legal problem with a form? Tell us, and earn $50!
 


HACKER SAFE certified sites prevent over 99.9% of hacker crime.


Buy This Form for 9.99  Professionally Formatted for Microsoft Word -- Click HERE!

Buy This Form for $9.99 Professionally Formatted for Microsoft Word -- Click HERE!

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: ...

Other Forms You May Need

Buy This Form for $9.99 Professionally Formatted for Microsoft Word -- Click HERE!

Buy This Form for $9.99 Professionally Formatted for Microsoft Word -- Click HERE!


 


For only $9.99 have this form emailed to you as a Microsoft Word document.

 



Question about this form?
Ask us, and we'll endeavor to post an answer as soon as possible.
 

First Name:
Last Name:
E-mail:
Question:

Characters
remaining:
This forum is not intended to provide legal advice, but rather information about the law. Submissions are subject to our terms and conditions of use.

For only 9.99 you can have this form emailed or faxed to you. We'll send you the form properly formatted and ready for your immediate use.
Attention attorneys and legal publishers:  sell us your legal forms and earn up to $2,500 or more!
"Are these forms valid in my state?"  At ILRG, we are committed to delivering top quality legal forms that are valid in all states.  We will pay $50 to anyone who brings to our attention any form on our site that is not compliant with U.S. state law.  See the terms and conditions for this offer for further information.

Attorney Referral Network:

Attention attorneys!  Would you like to increase your practice's income?  ILRG will soon introduce a new service that will help consumers locate and retain legal counsel in an exciting, innovative way. Qualified attorneys in the U.S. and Canada are being given an opportunity for a limited time to pre-register at no cost.  Attorneys who pre-register are guaranteed free registration when our new service goes live.  Gain new clients!  Be a rainmaker at your firm, and sign-up today!  [Learn More...]

© 1995-2014 Internet Legal Research Group
A product of Maximilian Ventures LLC
Reproduction in whole or in part without permission is prohibited. 111

Advertise with Us | E-Mail Webmaster | Subscribe to E-Mail Updates | Submit URL | Terms of Use | Privacy Policy