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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:


    Relationship status:
    SingleMarriedCommon Law

    Does your partner also require a representative?
    YesNo

    Partner Full Legal Name:


    B. Information about Your Representative

    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

    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:

    1. Major health care?

    2. YesNo
    3. Minor health care?

    4. 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.

    5. Deciding where and with whom you reside?

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

    8. YesNo
    9. 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?

    10. YesNo
    11. 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?

    12. YesNo
    13. Making arrangements for the temporary care, education, and support of:

      1. Your minor children

      2. YesNo
      3. Any other persons you care or support

      4. YesNo
    14. Making decisions to refuse or continue life-supporting care or treatment for you?

    15. YesNo

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

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

    2. ConsentRefuseBoth
    3. Psychosurgery?

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

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

    8. ConsentRefuseBoth
    9. 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?

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

    12. 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

    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

    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

    Additional Comments (if any):


    Required Consent and Agreement *

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