Government of Ontario: Ministry of Health
Statement of Representative Appointed Under the Mental Health Act to Give or Refuse Consent on Patient’s behalf to Access or Disclose Clinical Record
To: Officer in Charge of: (name of psychiatric facility)
I,
am willing to act as a representative for
am not
full name of patient
if she/he becomes mentally incapable to consent to/refuse access or disclosure of the clinical record.
date
signature of representative
print full name of representative
address
telephone -- home
telephone -- work
1471–41 (98/04)
7530–4753