DESIGNATION OF HEALTH CARE SURROGATE FOR MINOR I/WE Check one: ___________The natural guardian(s) as defined in s. 744.301(1), Florida Statutes ___________ The legal custodian(s); ___________ The legal guardian(s); 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 I/we am/are not able, or reasonably available to provide consent for medical treatment and surgical and diagnostic procedures: designate as my health care surrogate under s. 765.202, Florida Statutes: Name: Address. 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: Address. 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. Bar Form No. G-1.035 - 1 of 3 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 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: ____________________________________________ Signed on this day of , __________. _____________________________ SIGNATURE _________________________________ PRINTED NAME ______________________________ ______________________________ ADDRESS Witness 1 signature: Witness 2 signature: Witness printed name: Witness printed name: Witness Address: Witness Address: Date: Date: Signed on this day of , __________. _____________________________ SIGNATURE _________________________________ PRINTED NAME ADDRESS Bar Form No. G-1.035 - 2 of 3 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com Witness 1 signature: Witness 2 signature: Witness printed name: Witness Address: Witness printed name: Witness Address: Date: Date: Bar Form No. G-1.035 - 3 of 3 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com