Government of Ontario: Ministry of Health

Upon the advice of his/her attending physician that

(name of patient in full)
(home address)

requires hospital treatment that cannot be supplied in this facility, I,

officer-in-charge of
(psychiatric facility)

hereby transfer the said patient to (name of public hospital)
for such treatment.

Note:
Where the patient is subject to detention, a copy of the document authorizing such detention must accompany this document.

____________________________________(signature of officer-in-charge)

Date (day/month/year)