Appendix B: Health Care Consent Act, 1996 Forms

AuthorRichard D. Schneider; Caitlin Pakosh; Lora Patton
Pages610-635

APPENDIX B
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 Forms Form A

Consent and
Capacity Board
Form AApplication to the Board to Review a Finding of
Incapacity under Subsection (), () or () of the
Section  – Applicant (Patient/Resident)
Last Name First Name
Unit No. Street No. Street Name PO Box
City/Town Province Postal 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 Name First Name
Unit No. Street No. Street Name PO Box
City/Town Province Postal 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 Name First Name
Unit No. Street No. Street Name PO Box
City/Town Province Postal Code
Telephone No. (including area code) Fax No. Email Address

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