My Substitute Decision-Maker Card

Use this form to record your substitute decision-makers.
You will be asked to indicate their relationship to you and their position on the Ontario SDM hierarchy.
Once completed, you may print out this form.
If you are listing someone other than your automatic SDMs please make sure you have completed the legal paperwork.
For more information about who can be your SDM, click here

Enter information about your SDM in the fields below:

I have discussed/or will discuss my wishes for future healthcare with my SDM(s) named below.

Based on the hierarchy of SDM in Ontario Law, I believe that the the information is correct at the time of completion:

My substitute decision maker(s) are:

What is the level of this substitute decision maker based on the hierarchy of SDM in Ontario Law?

First and last name:

Relationship of this substitute decision maker to me:

Phone number:

Alternative phone number:

Address:

E-mail address:

This person was appointed through a Power of Attorney for Personal Care:

Yes

Location of the current Power of Attorney for Personal Care (original document):

Just because you have listed the names of people to be your substitute decision maker in this workbook that does NOT mean that these people have the right to be your SDM(s) in the future. The SDM(s) will need to be:

The highest-ranking people in your life on the hierarchy list of SDM(s) AND
Meeting the requirements of being an SDM.

This workbook is NOT a Power of Attorney for Personal Care

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