Designation of health care surrogate for a minor; suggested form.
F.S. 765.2038
in effectA written designation of a health care surrogate for a minor executed pursuant to this chapter may, but need not, be in the following form:
DESIGNATION OF HEALTH CARE SURROGATE
FOR MINOR
I/We,
(name/names)
, 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)
Source: FL Statutes (Official Site)URL: https://www.flsenate.gov/Laws/Statutes/2025/Chapter765/AllFetched: 7/8/2026