File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR ORDER FOR CONSENT TO A PRESCRIBED MEDICAL PROCEDURE
		
	*Guardianship and Management of Property Act 1991		

I wish to apply for an Order by the ACT Civil and Administrative Tribunal for Consent to a Prescribed Medical Procedure 

DETAILS OF PROTECTED PERSON
Miss
Mrs/Ms	
Mr
Other
_____________________________________________________________________
		(Given Names)				 (Surname)

Current Address 

_____________________________________________________________________

__________________________________________________Postcode__________

Telephone (H)__________________________ (W) __________________________ 

EMAIL______________________________________________________________

Date of Birth ____/____/____

What disability/condition does the person have? 

_____________________________________________________________________

Is there a current order appointing a guardian for the person? If so, please provide details (if available):

Order No. __________________  Date of Order _____/_____/_____

Name, address and telephone details of Guardian:-

Name
	_______________________________________________________________

Address of Guardian and/or Manager
_____________________________________________________________________
cont. over page
Telephone___________________________________________________________

EMAIL_____________________________________________________________
									
WHAT IS THE PRESCRIBED MEDICAL PROCEDURE THAT YOU BELIEVE IS NECESSARY FOR THE PERSON FOR WHOM THE ORDER IS SOUGHT?

	Abortion                            	 Reproductive Sterilisation

	Contraception		      	  Hysterectomy
	Removal of non-regenerative tissue for transplantation
	Other Prescribed medical or surgical procedure

DO YOU WISH TO MAKE ANY COMMENTS IN SUPPORT OF YOUR APPLICATION?
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

DETAILS OF PROTECTED PERSON'S MEDICAL PRACTITIONER
Name of Doctor/Psychologist/Other Professional involved with the person:
           ______________________________________________________________

Address:____________________________________________________________
Telephone:__________________________________________________________

EMAIL_____________________________________________________________
DETAILS OF APPLICANT
Miss
Mrs/Ms	
Mr
Other
_____________________________________________________________________
		(Given Names)				 (Surname)

Current Address 

_____________________________________________________________________

__________________________________________________Postcode__________

Telephone (H)__________________________ (W) __________________________ 

EMAIL_____________________________________________________________

Date of Birth ____/____/____

Relationship to Protected Person ____________________________________

Signature _____________________________________  Date _____/____/____