Fla. Stat. 765.2038
Designation of health care surrogate for a minor; suggested form

DESIGNATION OF HEALTH CARE SURROGATEFOR 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: Section 765.2038 — Designation of health care surrogate for a minor; suggested form, https://www.­flsenate.­gov/Laws/Statutes/2024/0765.­2038 (accessed Aug. 7, 2025).

Current through Fall 2025

§ 765.2038. Designation of health care surrogate for a minor; suggested form's source at flsenate​.gov