Appendix B: Health Care Consent Act, 1996 Forms

• Author: Richard D. Schneider; Caitlin Pakosh; Lora Patton
• Pages: 610-635

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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

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Consent and

Capacity Board

Form A – Application to the Board to Review a Finding of

Incapacity under Subsection (), () or () of the

Health Care Consent Act.

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