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DECLARATION OF INCAPACITY BY DESIGNATED PERSON

I,                           ,

of                           , in the province of                           , am the person designated in the attached document to determine the maker’s capacity, declare that I have consulted with the physician or psychologist indicated below, and I am of the opinion that the maker is not competent to make decisions about his or her health or personal care for the following reasons:

                        _______                                                 _________

(Signature)                                                (Address)

                        _______                                                __________

(Print name)                                          (Phone number)

(Date)

Confirmation of Physician or Psychologist

I, the physician or psychologist referred to above, confirm that I was consulted by the individual named above regarding the capacity of        ____________
(maker of health-care directive).

(Signature)                        (Office Address)

 (Print name of physician or psychologist)                        (Phone number)

 (Professional designation)                        (Date)