Title XLIV, Chapter 765 (Section 765.203)

Name: ____________

Title XLIV, Chapter 765 (Section 765.203)

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:

Name:    ________________________________
Address: ________________________________	
             ________________________________
Phone:   ________________________________

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

Name:    ________________________________
Address: ________________________________	
             ________________________________
Phone:   ________________________________

I fully understand that this designation will permit my designee to make health care decisions, except for anatomical gifts, unless I have executed an anatomical gift declaration pursuant to law (Uniform Donor Form), 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.

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:

Name:     ________________________________
Address:  ________________________________
              ________________________________

NName:   ________________________________
Address:  ________________________________
              ________________________________

Signed:________________________________
Date: ________________________________

Witnesses:

1. ______________________

2. ______________________

(At least one witness must not be a husband or wife or a blood relative of the principal)

UNIFORM DONOR FORM

Title XLIV, Chapter 765 (Section 765.514)

The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The words and marks below indicate my desires:

I give:

_____ any needed organs or parts;

_____ only the following organs or parts [specify the organ(s) or part(s)]: __________________________________.

for the purpose of transplantation, therapy, medical research, or education; _____ my body for anatomical study, if needed. Limitations or special wishes, if any: _____________________________________________

__________________________________________________________

__________________________________________________________

Signed by the donor and the following witnesses in the presence of each other:

Donor's Signature _____________________ Donor's Date of Birth __________

Date Signed ____________ City and State _____________________________

Witness _____________________ Witness ___________________

Street Address_______________ Street Address_______________

City ______________ State____ City ______________ State____