NOTIFICATION OF ANTICIPATED DEATH AT HOME AND DIRECTION FROM THE PATIENT'S PHYSICIAN

  • NOTIFICATION OF ANTICIPATED DEATH AT HOME AND DIRECTION FROM THE PATIENT'S PHYSICIAN

  • 1) Family/Patient completes the "Patient Information" section below

    2) Print the completed form and bring it to your physician's appointment

    3) Physician completes and signs the "Physician Certification" section

    3) The physician distributes copies to all required parties listed below

  • To:

    • Local or Regional EMS System: *   *   *   *   
    • Tillwell Inc., 1-5 Fast Lane, Headingley, MB R4H 1B4, Phone: 204-885-0409
    • Office of the Chief Medical Examiner, 210 - 1 Wesley Avenue, Winnipeg, MB R3C 4C6
    • Local RCMP (if in rural area): *   *   *   *   
    • Physician's file
    • Place in prominent location in the patient's home

  • SECTION A: PATIENT INFORMATION

    TO BE COMPLETED BY FAMILY/PATIENT BEFORE PHYSICIAN VISIT
  •  - -
  • Format: (000) 000-0000.

  • SECTION B: PHYSICIAN CERTIFICATION

  • TO BE COMPLETED AND SIGNED BY ATTENDING PHYSICIAN

    This notice is being sent to the recipients listed above in anticipation of the death at home of my patient identified in Section A above.

    As attending physician, I or my designate will be responsible for completing the Medical Certificate of Death within the required 48 hours of death.

    TO BE COMPLETED AND SIGNED BY ATTENDING PHYSICIAN

    This notice is being sent to the recipients listed above in anticipation of the death at home of my patient identified in Section A above.

    As attending physician, I or my designate will be responsible for completing the Medical Certificate of Death within the required 48 hours of death.

    Printed Name of Physician: ________________________________________________

    Physician's Signature: ____________________________________________________

    Date: ___________________________________________________________________

    Physician's Address: _____________________________________________________

    City: _________________ Prov: _______ Postal Code: ___________________

    Phone #: _________________________ Fax #: _____________________________

    Medical License Number: __________________________________________________

    Covering Physician Information (if applicable):

    Name: ___________________________________________________________________

    Phone #: _________________________ Fax #: _____________________________

    License Number: _________________________________________________________

  • Should be Empty: