My name is (full name of applicant) I withdraw my application(s) to the Consent and Capacity Board dated (date)
involuntary status (Form 16) finding of incapacity with respect to treatment (Form A) finding of incapacity with respect to admission to a care facility (Form A) finding of incapacity with respect to a personal assistance service (Form A) finding of incapacity to manage my property (Form 18) being appointed as a patient's representative with respect to his or her treatment, admission to a care facility, or personal assistance service (Form C) whether the substitute decision-maker complied with the principles for giving or refusing consent under the Health Care Consent Act (Form G) Other (please specify)
(signature of applicant's lawyer/agent or applicant[if unrepresented])* (date of signature) (print full name) (telephone no.) -
* If the applicant is a patient in a psychiatric facility and does not have legal representation, this section must be completed:
My name is (print full name)
I have witnessed the patient's signature. the patient will not sign the Notice of Withdrawal, but has authorized me to make all necessary arrangements to withdraw the application.
(signature of witness) (date of signature) (title or relationship to the patient) (telephone no.) -
For your information:
Application forms are treated independently: You must check every applicable box if you intend to withdraw more than one application.
Withdrawal of Forms B, C, D, E, F, or G: If one of these applications is withdrawn, the law will no longer provide that the patient is deemed to have applied for a review of his or her capacity to make the relevant decision. If the subject of the application still wants the Board to review a finding of incapacity, he or she must bring an application under a Form A.
4323-04(04/07) www.ccboard.on.ca (Disponible en version française)