Form 15 (YG4002) "Application for Transfer of a Non-resident Involuntary Patient" - Yukon, Canada

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Download Form 15 (YG4002) "Application for Transfer of a Non-resident Involuntary Patient" - Yukon, Canada

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FORM 15 – MENTAL HEALTH ACT, SECTION 25(1)
APPLICATION FOR TRANSFER OF A
NON-RESIDENT INVOLUNTARY PATIENT
This form must be completed by the attending physician or the two physicians who have completed Form 7
(Certificate of Involuntary Admission).
Copies must be provided to the:
Chief Executive Officer, Whitehorse General Hospital; and
Director of Insured Health Services.
IN THE MATTER OF the Mental Health Act
AND IN THE MATTER OF _________________________________________________________ hereinafter called the patient.
NAME OF PERSON
I, ____________________________________ , a medical practitioner licensed to practise in the Yukon Territory, hereby approve
transfer of the patient, a resident of ______________________________________, to _____________________________________,
a provincially approved facility located at _________________________________, in the province of ________________________
Y Y Y Y
/
M M
/
D D
on or about ____________________.
I formed the opinion as to the need to transfer the patient to the above-named facility based on the following facts:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
The patient is apparently competent to consent to treatment, and has been advised of the intention to transfer him/her.
The patient is apparently not competent to consent to treatment and the substitute decision-maker has been advised of
the intention to transfer him/her.
DATED at ______________________________________,
____________________________________________________
Signature of physician
this ____ day of _________________________, 20 ____.
____________________________________________________
Printed name physician
____________________________________________________
_______________________________________________
Signature of physician
Signature of witness
____________________________________________________
Printed name physician
Information on this form is being collected pursuant to the Mental Health Act to provide notice to Whitehorse General Hospital and Insured Health Services regarding an
intention to transfer a patient. For more information, contact the Health and Social Services ATIPP Coordinator (H-1), Box 2703, Whitehorse, Yukon Y1A 2C6, (867) 667-3010.
YG(4002EQ)F1 Rev.07/2019
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FORM 15 – MENTAL HEALTH ACT, SECTION 25(1)
APPLICATION FOR TRANSFER OF A
NON-RESIDENT INVOLUNTARY PATIENT
This form must be completed by the attending physician or the two physicians who have completed Form 7
(Certificate of Involuntary Admission).
Copies must be provided to the:
Chief Executive Officer, Whitehorse General Hospital; and
Director of Insured Health Services.
IN THE MATTER OF the Mental Health Act
AND IN THE MATTER OF _________________________________________________________ hereinafter called the patient.
NAME OF PERSON
I, ____________________________________ , a medical practitioner licensed to practise in the Yukon Territory, hereby approve
transfer of the patient, a resident of ______________________________________, to _____________________________________,
a provincially approved facility located at _________________________________, in the province of ________________________
Y Y Y Y
/
M M
/
D D
on or about ____________________.
I formed the opinion as to the need to transfer the patient to the above-named facility based on the following facts:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
The patient is apparently competent to consent to treatment, and has been advised of the intention to transfer him/her.
The patient is apparently not competent to consent to treatment and the substitute decision-maker has been advised of
the intention to transfer him/her.
DATED at ______________________________________,
____________________________________________________
Signature of physician
this ____ day of _________________________, 20 ____.
____________________________________________________
Printed name physician
____________________________________________________
_______________________________________________
Signature of physician
Signature of witness
____________________________________________________
Printed name physician
Information on this form is being collected pursuant to the Mental Health Act to provide notice to Whitehorse General Hospital and Insured Health Services regarding an
intention to transfer a patient. For more information, contact the Health and Social Services ATIPP Coordinator (H-1), Box 2703, Whitehorse, Yukon Y1A 2C6, (867) 667-3010.
YG(4002EQ)F1 Rev.07/2019
Print
Clear