MAID Forms

Instruction for Written Request

The “Written Request” is the first step in expressing your interest in medical assistance in dying (MAID). This document is required by law and is essential in starting the process for MAID;.

To get started, we will send you the document by email, mail or fax, and provide instructions on how to complete it. You may also complete the form in-person if you so choose.

Please note: The Written Request does not need to be completed prior to assessments being done. In addition, the document is not consent for MAID provision and does not determine your eligibility. You may change your mind at any time.

Key information to keep in mind:

1. Ensure the Patient Information is accurate and free of any errors. 
2. Read the paragraph under Patient Request carefully.
3. If you agree with the statement, you must sign and date the document in the presence of a witness. 
4. The witness must;
   1. Be at least 18 years of age.
   2. Confirm the identity of the patient. 
   3. Understand the nature of the request for MAID. 
   4. Not know or believe that they are a beneficiary of the estate of the patient making the request. 
   5. Not be an owner-operator of a health care facility where the patient is receiving treatment, or of a facility in which the patient resides. 
5. If you are physically unable to sign, you may have a proxy sign on your behalf. This individual cannot make decisions for you. The proxy and witness must sign the document in your presence and under your direction. 
   
   Please Note:  The proxy must meet the same criteria as the witness (see above). They also cannot serve as the witness. 

In the event you are having difficulty obtaining a witness, please contact us toll free at 1-833-473-6243 (MAID) for assistance.