Government of Ontario: Ministry of Health

Re: (print full name of patient)

of (home address)

I, (print name of physician)

of (name of psychiatric facility)

state that:

1. I examined the above-named patient on (day / month / year)

2. I observed the following facts indicating incapacity:

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

4. I am of the opinion that the above-named patient will not, upon discharge, be capable to manage his/her property.

(day / month / year)

(signature of physician)

Note:

1. The physician shall promptly advise the patient of the notice of continuance by giving the patient a Form 33 and shall notify a right adviser.

2. The Officer-in-Charge shall transmit the Notice of Continuance to the Public Guardian and Trustee.