Designation of Health Care Surrogate

A Designation of Health Care Surrogate form is a legal document that allows an individual (the "principal") to appoint someone they trust to make medical decisions on their behalf if they become incapacitated or unable to make decisions themselves. This appointed person is called a health care surrogate or medical proxy.

When Is This Health Care Surrogate Form Template Needed?

1. Medical Incapacity – If a person becomes unconscious, mentally impaired, or otherwise unable to make informed health care decisions, a designated surrogate can step in to make choices about treatment, procedures, and care.

2. Serious Illness or Surgery – Individuals undergoing major surgery or managing chronic illnesses may complete this form as a precautionary measure.

3. Elderly or Terminally Ill Patients – Seniors or those with progressive conditions (e.g., dementia) often designate a surrogate to ensure their medical wishes are followed.

4. Unexpected Emergencies – Accidents or sudden health crises may render someone incapable of making decisions, and this form ensures that a trusted individual has the authority to act in their best interest.

Please note Healthcare Surrogate Designation requirements may vary by jurisdiction—please consult a lawyer to ensure compliance with local laws.

How to use this document?

1. Fill in your full name and designate a primary health care surrogate (and an alternate, if desired).

2. Specify any special instructions regarding your medical care.

3. Provide a copy to your health care surrogate(s) so they understand their responsibilities.

4. Keep an easily accessible copy in case of a medical emergency.