DESIGNATION OF HEALTH CARE SURROGATE


Name___________________________________________________________________
            (Last)                  (First)            (Middle)


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: _______________________________________________________________

_________________________________________________ Zip Code:_____________

Phone:_________________________________________________________________


If my surrogate is unwilling or unable to perform his duties, I wish to designate as my alternate 

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 authorizes my admission to or transfer from a health care facility.  


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: __________________________________________________________________


One of the two witnesses must not be related to Declarant


Witnesses: 1._____________________________________________________________

           2._____________________________________________________________