HEALTHCARE PROXY DESIGNATION AND ACCEPTANCE LETTER

Pursuant to Florida Statutes, this designation is made on behalf of

__________________________________________________________________________________.
(Patient’s name, address)

In light of the fact that ______________________________________________________________,
                                                      (Patient’s name)

is not able to make informed decisions regarding his/her health care needs,  it is requested that

 ________________________________________________________________________________,
                        (Proxy’s name, address)

_______________________________________, is designated as
              (Relationship to patient)

Health Care Proxy on behalf of _____________________________________.
                                                                     (Patient’s name)

By signing the acceptance below ____________________________________, agrees to comply with the
                                                                    (Proxy’s name)

 responsibilities of this designation per Florida Statutes.

Sincerely,

__________________________________
       (Patient’s Physician Signature)

__________________________________
           (Print Physician’s Name)

Acceptance of Health Care Proxy Designation

I __________________________________________, do hereby accept my appointment   
                         (Proxy’s name)

as Health Care Proxy on behalf of ____________________________________________
                                                                                  (Patient’s name)

Signed this ________________day of ___________________, ____________.

_________________________________________
                 (Proxy’s Signature)