Roger Neilson House



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Roger Neilson House

Alternate Decision Maker for Medical Care Agreement

I, __________________________, of the City of ______________, in

(parent/legal guardian)

the Province of ________________ make the following arrangements for the care of my child ________________________.

(name of child)

1). I am the parent/legal guardian of _____________________,

(name of child)

Date of Birth _______________.

2). I hereby give permission to ________________________________to

(name of alternate decision maker)

make whatever medical and/or personal decisions are necessary in relation to my said child whilst I am absent from the City of ______________, Ontario from

___________________to ____________________or longer if I continue

(date agreement starts) (date agreement ends)

to be absent.

3). The alternate decision maker is aware of my child’s medical history, his/her Palliative Plan of Care and Consent form have been reviewed and the alternate decision maker knows my wishes for my child’s personal and medical care. The alternate decision maker will care for my child if cancellation is necessary or accompany my child to CHEO in the event of an acute illness.

4). I make this agreement to facilitate the decision-making process for my said child during my absence and for no other or improper purpose.

This document is signed at the City of _______________, in the Province of Ontario, on

_________________.

(date)

Parent/Legal Guardian signature _________________________________

Alternate decision maker signature _______________________________

Witness _________________________/_____________________________

(name) (signature)

Revised Aug/2017

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