Government of Ontario: Ministry of Health and Long-Term Care

Statement of Disagreement with Clinical Record under Section 36 of the Mental Health Act

To: Officer in Charge of: (name of psychiatric facility)
I,(print full name of person)
of,(address)
hereby state that I disagree with the information contained in the clinical record of (name of patient)
Casebook no.
and hereby require that this“Statement of Disagreement” be attached to the above clinical record with respect to a correction or corrections requested but not made.

Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information
Information in Clinical Record Disagreement/Preferred information

signature

Date day month year

1469–41 (99/08)*
7530–4747