Trusted Person Designation (Document Template)

I, the undersigned, [First Name Last Name] , [date of birth] , [skill]


Mr./Mrs. [First Name Last Name] ,

Born on [date of birth]

Resident [skill]


[email address]

Relationship with the person: parent/doctor/close friend

To assist me in case of need as a trusted person: until I decide otherwise / only for the duration of my stay in the institution [name of the establishment]

I have noted that Mr. / Mrs. [First Name Last Name]

  • may, at my request, accompany me in the steps concerning my care and attend the medical interviews,
  • may be consulted by the team treating me in case I am not able to express my will regarding the care provided to me and must receive the necessary information to do so. In these circumstances, no major intervention can be carried out without this prior consultation except in urgent cases or impossibility to contact him or her,
  • will not receive information which I consider confidential and which I have indicated to the doctor,
  • will be informed by me of this designation and that I will have to ensure its agreement.

I can end this decision at any time and by any means.

Done at [location] , on [date]

Your signature

Signature of Designated Person

Verified 16 March 2021 - Directorate for Legal and Administrative Information (Prime Minister)

For details, please use the practical information sheets :

J'ai réalisé une démarche administrative

Je donne mon avis sur Services Publics +. L'administration concernée me répondra.