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1998 Florida Statutes
Suggested form of designation.
765.203 Suggested form of designation.--A written designation of a health care surrogate executed pursuant to this chapter may, but need not be, in the following form:
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: