Florida Statutes
Part II - Health Care Surrogate (Ss. 765.201-765.205)
765.2038 - Designation of health care surrogate for a minor; suggested form.

DESIGNATION OF HEALTH CARE SURROGATEFOR MINOR
I/We,   (name
ames)  , 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)  

History.—s. 11, ch. 2015-153; s. 86, ch. 2016-10.

Structure Florida Statutes