Government of Ontario: Ministry of Health

Re: (print full name of patient admitted to the psychiatric facility)

of (home address)

I, (print name of physician)

of (name of psychiatric facility)

state that:

1. I examined the above-named patient on

2. I observed the following facts indicating incapacity:

3. The following facts, if any, indicating incapacity were communicated to me by others:

I certify that the above-named patient is incapable to manage his/her property

(date)(day/month/year)

(signature of physician)

Note:

The physician shall promptly advise the patient of the certificate of incapacity by giving the patient a Form 33 and shall notify a right adviser

This form only applies in respect of a patient admitted to a psychiatric facility and not to an out-patient. Section 1 defines a "patient" as a person under observations, care and treatment in a psychiatric facility.

"Out-patient" means a person who is registered in a psychiatric facility for observations or treatment, or both but who is not admitted as a patient and is not the subject of an application for assessment.

A "psychiatric facility" means a facility for the observation, care and treatment of persons suffering from mental disorder and designated as such by the Minister.