CONSENT FOR CHILDREN TO BE TREATED AT CHEO*  (Download Form)

HCP: __________________________        DOB: ___________________________

1. Please record the name of the adult person accompanying this child to Ottawa:
   Escort: __________________________________________________________
   Relationship to child: _______________________________________________
   Address and contact number: ________________________________________
2. Is this Escort person the Legal Decision-Maker** for this child: YES NO -
3. If no, please indicate the name and contact number for the Legal Decision-Maker for this
   child: ___________________________________________________________
   Name: __________________________________________________________
   Address and Contact Number: _______________________________________
   
4. Please advise the Legal Decision-Maker of the following:
   
   (a) This child is being transferred to Ottawa for medical examination andlor treatment at
   the Children's Hospital of Eastern Ontario (CHEO) under the laws of Ontario. A consent
   form will be required at CHEO.
   
   (b) The Legal Decision-Maker for the child must give their consent to allow transport of
   the child in the accompaniment of this Escort person.
   
   (c) The Legal Decision-Maker must be available to provide consent to treatment to
   CHEO when the child arrives in Ottawa. Telephone consent to the physician at CHEO is
   valid consent.
5. Name of Health Professional filling out this form:
   ___________________________________________________________________
   Signature: __________________________________________________________
   Date: ______________________________________________________________
   

* This form must be filled out by a Health Professional in Nunavut and its contents discussed
with the Legal Decision Maker for the child (and the escort person, if different person). A
copy of the form must accompany the child to CHEO.

** "Legal Decision-Maker" is the natural parent, parent by adoption or legal guardian of the child
under the laws of Nunavut.