Government of Ontario: Ministry of Health

Re: (full name of patient)

of (home address)

I, (name of physician)

of (name of psychiatric facility)

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

2. I hereby cancel the certificate of incapacity issued in respect of the above-named patient on (day / month / year)

(signature of physician)

Note: The Officer-in-Charge shall transmit the notice of cancellation to the Public Guardian and Trustee.