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Get FL Designation of Health Care Surrogate 2004

for medical treatment and surgical and diagnostic procedures, I wish to designate, as my surrogate for health care decisions: Name Street Address City Phone State Zip If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate: Name Street Address City Phone State Zip I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; or apply for p.

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