Ministry of Health
Medical Assistance in Dying means: (a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or (b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.
Authorized third person is a person who is at least 18 years of age and who understands what it means to request medical assistance in dying and who does not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death may sign and date the request in the presence and on behalf of the person requesting medical assistance in dying.
An independent witness is any person who is at least 18 years of age and who understands the nature of the request for medical assistance in dying who (a) does not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death; (b) is not an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides. An independent witness may include a person who is paid to provide health care services or personal care to the person requesting medical assistance in dying. A medical assistance in dying provider, assessor or where applicable, the consulting practitioner with expertise in the condition causing the person’s suffering is not permitted to act as a witness.
A person is considered to have a grievous and irremediable medical condition where:
Note: Persons whose sole underlying medical condition is a mental illness, and who otherwise meet all eligibility criteria, are not currently eligible for MAID. The term mental illness does not include neurocognitive or neurodevelopmental disorders, or other conditions that may affect cognitive abilities.
The use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements.
Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.
Last Name First Name
Date of Birth (yyyy/mm/dd)
Health Insurance Number (e.g., OHIP Number) Not Applicable Version Code
Province or Territory that Issued Health Insurance Number AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Postal Code Associated with Patient's Home Address Patient does not have a home address
You must personally verify all data in this section and sign your own name. If you are unable to sign for yourself you may ask an authorized third person to complete it for you and sign their name in Section 3 under authorized third person signature.
I, (Last Name, First Name) request that a doctor or nurse practitioner help me to die.
I confirm that:
I am eligible for health services funded by a government in Canada (i.e., I have a valid OHIP card or proof of other Canadian publicly- funded health insurance – e.g., from another province) or, but for any applicable minimum period of residence or waiting period, I would be eligible for health services funded by a government in Canada.
I am at least 18 years of age.
I have been informed by my doctor or nurse practitioner that I have a grievous and irremediable condition.
I am asking for help to die voluntarily and not as a result of pressure from others.
I am giving my informed consent to receive medical assistance in dying, and have been informed of the means that are available to me to relieve my suffering, including palliative care.
Signature (Patient) Date (yyyy/mm/dd)
Unit Number Street Number Street Name PO Box City, Town or Village Province AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Postal Code Telephone Number ext. Relationship to Person Requesting Medical Assistance in Dying
By signing below on the person’s behalf, I declare that:
I am at least 18 years of age;
I understand the nature of the person’s request for medical assistance in dying;
I do not know or believe that I am a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death; and
I am signing under the person's presence, on the person’s behalf and under the person’s express direction.
Signature (Third Person) Date (yyyy/mm/dd)
This section must be completed by one independent witness. An independent witness may include a person who is paid to provide health care services or personal care to the person requesting medical assistance in dying. A medical assistance in dying provider, assessor, or where applicable, the consulting practitioner with expertise in the condition causing the person’s suffering is not permitted to act as a witness.
Unit Number Street Number Street Name PO Box City, Town or Village Province AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NL - Newfoundland and Labrador NS - Nova Scotia NT - Northwest Territories NU - Nunavut ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon Postal Code Telephone Number ext.
Family * (Specify)
Volunteer
Friend
Neighbour
Hospital/care staff
Other (Specify)
* Neither myself nor my spouse are beneficiaries under the will of the person making the request, or a recipient, in any other way, of a financial or some other material benefit resulting from that person’s death.
By signing below, I declare that:
I do not know or believe that I am (a) a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or some other material benefit resulting from that person’s death; (b) are the owner or operator of any health care facility at which the person making the request is being treated or in any facility in which that person resides.
Signature (Witness) Date (yyyy/mm/dd)
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