NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services
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ATTACHMENT B<br />
SPECIAL AUTHORITY TO PROXIES (Optional)<br />
(A certificate of Legal Consultation must be filled out<br />
by a lawyer if you fill out anything in this Attachment.)<br />
1. Authority requiring Legal Advice<br />
I grant my proxies additional authority to make decisions for the following matters.<br />
I underst<strong>and</strong> that this specific authority is only valid if I consult with a lawyer <strong>and</strong><br />
have the lawyer complete a certificate of legal advice:<br />
(Initial the authority you want to give to your proxies.)<br />
A. Authority to physically restrain, move or manage me when necessary <strong>and</strong><br />
despite my objections in the following circumstances:<br />
(Examples: • when I exhibit the following symptoms of my illness (e.g. symptoms of bipolar<br />
affective disorder or symptoms of toxins in the body as a result of kidney disease)<br />
• when two health professionals <strong>and</strong> a certain family member people agree that I am<br />
exhibiting symptoms of my illness)<br />
B. Authority to give consent in the following circumstances to the following kinds<br />
of health care even if I am refusing to give consent at the time:<br />
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