Appendix B: Health Care Consent Act, 1996 Forms
Author | Richard D. Schneider; Caitlin Pakosh; Lora Patton |
Pages | 610-635 |
APPENDIX B
Health Care Consent Act, 1996 Forms
Form A Application to the Board to Review a Finding of Incapacity under Subsection (), ()
or () of the Act
Form B Application to the Board to Appoint a Representative under Subsection (), () or
() of the Act
Form C Application to the Board to Appoint a Representative under Subsection (), ()
or ()
Form D Application to the Board for Directions under Subsection (), () or () of the Act
Form E Application to the Board for Permission to Depart from Wishes under Subsection (),
() or () of the Act
Form F Application to the Board with Respect to Place of Treatment under Subsection ()
of the Act
Form G Application to the Board to Determine Compliance under Subsection (), () or
() of the Act
Form H Application to the Board to Amend the Conditions of, or Terminate the Appointment of
a Representative under Subsection () and (), () or () of the Act
Health Care Consent Act, 1996 FormsForm A
Consent and
Capacity Board
Form A – Application to the Board to Review a Finding of
Incapacity under Subsection (), () or () of the
Section – Applicant (Patient/Resident)
Last NameFirst Name
Unit No.Street No.Street NamePO Box
City/TownProvincePostal Code
Telephone No. (including area code)Fax No.Email Address
Section – Application Type
I apply to the Board for a review of:
a health practitioner’s nding that I am incapable with respect to the following treatment
Specify:
an evaluator’s nding that I am incapable with respect to my admission to a care facility
an evaluator’s nding that I am incapable with respect to a personal assistance service.
Note: Applicant must be a resident in a Long-Term Care Facility
Section – Person Who Made the Finding of Incapacity
Note: An application may only be made if a health practitioner has made a relevant nding of incapacity
Last NameFirst Name
Unit No.Street No.Street NamePO Box
City/TownProvincePostal Code
Telephone No. (including area code)Fax No.Email Address
Section – Health Practitioner Who Proposed the Treatment
If this application refers to treatment, provide the contact information about the person proposing
treatment
Same as Section
Last NameFirst Name
Unit No.Street No.Street NamePO Box
City/TownProvincePostal Code
Telephone No. (including area code)Fax No.Email Address
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