Designation of Healthcare Surrogate

Name_____________________________________________________________________________
LAST FIRST MI

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 healthcare decisions:

Name_____________________________________________________________________________

Address___________________________________________ City_____________________________

State/Zip_________________________________________ Phone_____________________________

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

Name_____________________________________________________________________________

Address___________________________________________ City_____________________________

State/Zip_________________________________________ Phone_____________________________

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

___ I do___ do not desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.

Additional instructions (optional)__________________________________________________________

__________________________________________________________________________________

I further affirm that this designation is not being made as a condition of treatment or admission to a healthcare facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they will know who my surrogate is.

Name________________________________________________________________________________