A Designation of Healthcare Surrogate

This has been prepared for notaries about the laws governing their duties and is not intended as legal advice. For additional information or for difficult situations, it may be advisable for the customer to seek the advice of a licensed attorney.

The Designation of Healthcare Surrogate must be signed in the presence of two adult witnesses, who must also sign the document.  If you are physically unable to sign, you may have another person sign for you in your presence and in the presence of the two witnesses. The persons you appoint as your surrogate and alternate surrogate cannot act as witnesses to this document. At least one of your witnesses must not be your spouse or a blood relative.