Description

Description

A health care surrogate authorization allows you to designate a person or persons of your choice authorized to make health care decisions and receive health care information on your behalf if you are ever incapacitated. These are often extremely useful in the event of emergency or accident.

Healthcare Surrogate

$75.00

Health Care Surrogate – The person(s) appointed are authorized to make medical decisions for you if you are unable to make them yourself. Please advise who you wish to name as your health care surrogate:

Name(Required)

Address(Required)

Home Address (required) City (required) State (required) Zip Code (required)

Home Telephone

Mobile Telephone(Required)

Email Address(Required)

Age(Required)

Relationship(Required)

If your surrogate is unwilling or unable to perform his/her duties, who do you wish to designate as your alternate surrogate?

Name

Address

Home Address (required) City (required) State (required) Zip Code (required)

Home Telephone

Mobile Telephone

Email Address

Age

Relationship

NOTE: AS A COURTESY, WE PROVIDE A PRE-MED GUARDIAN DESIGNATION AT NO ADDITIONAL CHARGE.”

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Healthcare Surrogate