Healthcare Surrogate Form

Healthcare Surrogate Form

A Healthcare Surrogate Form is a type of document used as a health care directive to designate a specific person to handle medical decisions in the event that you are unable to give these decisions directly. This document will detail decisions such as life support, organ donation, and DNR (do not resuscitate) instructions that the patient and doctor have already discussed. A Healthcare Surrogate Form template can be downloaded via the link below.

Alternate Name:

To complete a Healthcare Surrogate Form, include the following information:

  1. The patient's full name, address, and contact information.
  2. A statement by the patient stating that they are granting a designated individual to carry out the medical wishes of the patient in the event they are unable to do so.
  3. The name of the designated surrogate, as well as their address and contact information.
  4. Confirmation of the surrogate that they agree to abide by the wishes of the patient and will not counter decisions the patient and medical staff previously agreed to.
  5. A section listing out all medical procedures, diagnostics, or other decisions the patient has already made with their doctor or other medical staff. This section should be well-detailed with clear instructions in the event of various scenarios.
  6. Include a statement that the surrogate and patient are signing this document of their own free will and neither party has been forced to sign it under duress.

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