Representation Agreement (RA9) Intake Form

Thank you for selecting Open Door Law to potentially assist you with a Representation Agreement. Representation Agreements are highly effective documents that are used by one party to assist another with health and related matters. Please complete our Representation Agreement Intake Form as completely as possible as the information provided will be used to check for conflicts and comply with the Law Society of British Columbia’s identification requirements. By completing this form in advance, we can spend more time focusing on the agreement and its related issues. Submission of this form will help us assess your matter and whether we can help you. it should not be inferred that a lawyer client relationship is formed until we confirm this with you.

Please note that this form assumes that British Columbia law applies to you. We reserve the right to request additional information from you either before or during our meeting.

Print this form

If you would rather complete this form on paper, we also offer a PDF version that you can print, then mail or fax to us. (Details within)

Fields marked with * are required

A. Personal Information of the Donor

Your Full Legal Name:

First Name *

Middle Name

Last Name *

Name variation(s) or other names used

Street Address *

City *

Province *

Postal Code

Phone *

Email *

Relationship status:
SingleMarriedCommon Law

Does your partner also require a representative?
YesNo

Partner Full Legal Name:

First Name

Middle Name

Last Name

Name variation(s) or other names used

Street Address *

City *

Province *

Postal Code *

Phone

B. Information about Your Representative

First Name *

Middle Name

Last Name *

Street Address *

City *

Province *

Postal Code *

Phone *

Email *

Date of Birth

Occupation *

Relationship to You: * (e.g. spouse, daughter, friend)

Do you have an alternate person you wish to appoint as as your alternate representative?
YesNo

What is the working relationship between your primary and alternate representatives?
Each of them can act separatelyThey must act together

First Name

Middle Name

Last Name

Street Address *

City *

Province *

Postal Code *

Phone

Date of Birth

Occupation

Relationship to You: (e.g. spouse, son, daughter, friend)

Do you have a valid power of attorney?
YesNo

If no, do you require a power of attorney?
YesNo

If yes, please fill out our Power of Attorney Intake Form.

Do you wish to appoint a monitor?
YesNo monitor wanted/required

If yes, please contact our office to discuss further.

C. Health or Personal Care Decisions

Do you want your representative to make decisions concerning:

Major health care?

YesNo

Minor health care?

YesNo

Major health care includes:

Major surgery
Any treatment involving a general anesthetic
Major diagnostic or investigative procedures
Radiation therapy
Intravenous chemotherapy

Electroconvulsive therapy
Kidney dialysis
Laser surgery
Any other health care designated by Regulation to or defined by the Health Care (Consent) and Care Facility (Admission) Act, as major health care

Minor health care means any health care that is not major health care.

Deciding where and with whom you reside?

YesNo

Deciding whether to physically restrain, move, or manage you, or to have you physically restrained, moved, or managed, despite your objections?

YesNo

Giving consent to minor health care or major health care even though you may have refused to give consent previous times the health care was to be provided?

YesNo

Accepting a facility care proposal under the Health Care (Consent) and Care Facility (Admission) Act for you to be admitted to any kind of care facility?

YesNo

Making arrangements for the temporary care, education, and support of:
1. Your minor children
2. Any other persons you care or support
Making decisions to refuse or continue life-supporting care or treatment for you?

YesNo

Do you want your representative to be able to give or refuse consent on your behalf for:

Electroconvulsive therapy (unless recommended in writing by the treating physician and at least one other medical practitioner who has examined you)?

ConsentRefuseBoth

Psychosurgery?

ConsentRefuseBoth

Removal of tissue from your body for implantation in another human body or for medical education or research?

ConsentRefuseBoth

Experimental health care involving a foreseeable risk to you that is not outweighed by the expected therapeutic benefit?

ConsentRefuseBoth

Participation in a health care or medical research program that has not been approved by a committee referred to in section 2 of the Health Care Consent Regulation?

ConsentRefuseBoth

Any treatment, procedure, or therapy that involves using aversive stimuli to induce a change in behaviour?

ConsentRefuseBoth

When the time comes, do you wish to be allowed to “die with dignity” – i.e. not kept alive by artificial means or heroic measures/only to provide comfort measures? YesNo

In the situation of "dying with dignity", do you wish medication administered for pain, even if those drugs might cause you to die sooner? YesNo

Do you have any other specific directions concerning your health or personal care (e.g. no blood transfusions, die at home)? YesNo

Special Directions:

When do you want the Representation come into effect? ImmediatelyOnly when you are no longer capable of giving informed consent

D. Effective Date & Termination Date

When will the Representation Agreement be effective? On the date it is executedOn the date you decide to trigger it into effectOn mental infirmity as confirmed in writing by two (2) licensed doctors

When will the Representation Agreement be terminated? On death, revocation, or Court OrderOn date or specific event

Specify Termination Date or Event:

In the event that Medical Assistance in Dying (MAID) provisions permit a representative to give effect to your wishes, do you wish to give your representative the authority? (Note: This is not currently the law in BC)YesNo

E. Additional Information

Have you given a representation agreement to anyone else that remains valid?
YesNo

Are we revoking the existing representation agreement?
YesNo

Do you wish your representation agreement to continue if you lose capacity?
YesNo

Do you wish your representative to have the ability to appoint a replacement representative?
YesNo

Indicate how you would like your representative to be compensated for his or her time and effort on your behalf:
No fees should be paid (only reimburse out-of-pocket expenses)Other

For other, please specify:

Additional Comments (if any):

Required Consent and Agreement *
I consent to Open Door Law Corporation’s Privacy Policy and Terms of Use Disclaimer.

Print this form

A. Personal Information of the Donor

B. Information about Your Representative

C. Health or Personal Care Decisions

D. Effective Date & Termination Date

E. Additional Information

Open Door Law Corporation

P: 604-689-3667
F: 604-689-5843
E: info@opendoorlaw.com

Contact Us

Print this form

A. Personal Information of the Donor

B. Information about Your Representative

C. Health or Personal Care Decisions

D. Effective Date & Termination Date

E. Additional Information

Open Door Law Corporation

P: 604-689-3667 F: 604-689-5843 E: info@opendoorlaw.com

Contact Us

P: 604-689-3667
F: 604-689-5843
E: info@opendoorlaw.com