Plan G Formulary
If patient signs, only page 1 is needed.

Otherwise, click below for Exceptional Coverage if no MSP, or if patient does not/cannot sign, and complete page 2.
Patient unwilling/unable to sign. Or patient does not have MSP coverage. Complete page 2 please.
Verbal Declaration
Legal authority:
Stamp Signature
MHSUC Sites CYMH Sites
Subject:
Creative Commons License Created February 12 2016 by Dr. John Robertson, licensed under a GPL.   Update V8_Nov25_2023 by Dr. John Yap.
Complete this section and sign below ONLY if patient has no MSP coverage
Return to page 1 and complete details for legal authorty.
Subject:
Creative Commons License SA Plan G, created Feb_12_2016 by Dr. John Robertson, licensed under a GPL.   Update V8_Nov25_2023 by Dr. John Yap.
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