Health Care Surrogate Questionnaire
******Florida residents only--This document is specific to FLORIDA LAW******

Essential workers and teachers-obtain your free healthcare surrogate legal document through Law Office of Lori Vella. Please fill out this form very carefully. The information you provide will be used to create your legal document. If you have questions about completing this form, please contact:

☎️ 813-575-2201 text
✅ Download contact

Please note: Using this form to obtain a free healthcare surrogate does not create an attorney-client relationship between you and Law Firm of Lori Vella, PLLC. An attorney-client relationship is only created after we outline the services you are to receive and you sign a Legal Services Agreement with Law Office of Lori Vella, PLLC.

You are responsible to properly formalize the Healthcare Surrogate with witnesses.

Thank you for all you do!

Law Office of Lori Vella
Estate Planning and Business Attorney
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Email *
Full Legal Name: *
Physical Address (must be Florida address): *
Phone Number *
What is your county of residence? *
Who would you like to designate as your first surrogate?
Please list the name and contact details for the trusted family member or friend that you plan to name as your healthcare surrogate.
Surrogate’s Full Name: *
Surrogate’s Physical Address: *
Surrogate’s Phone Number: *
Your Relationship to Person: *
Who would you like to designate as your alternate surrogate?
Alternate Surrogate’s Full Name:
Alternate Surrogate’s Physical Address:
Alternate Surrogate’s Phone Number:
I acknowledge this is NOT an invitation to an attorney/client relationship and I should NOT rely on information presented here without seeking the legal advice of counsel with respect to my particular issues/family situation. I have been informed that a written legal representation agreement, specific to the individual client, is required before any relationship is formed with this law office. *
I agree the legal document will be created based upon the information I provide. *
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