We ask that you complete this questionnaire as thoroughly as possible before we meet because it will provide us with essential information and help us to identify the items we should discuss with you. Please call us if you have any questions about completing this questionnaire.

The questionnaire is divided into three parts. The first part asks for information about you and your family. The second part is intended to assist you to decide what should be in your Representation Agreement. Although you may not be able to answer all the questions in that part, you will at least have an opportunity to think about them, and, perhaps, discuss them with your doctor before we meet. The third part is for our use.

The questionnaire may not elicit from you all the information you wish to give us or that we will wish to obtain from you. Please make note of all additional information concerning you, your family, and your wishes that you feel may be necessary or helpful to us in advising you.

Please note that the questionnaire assumes that only British Columbia law applies to you. If this situation is not the case, it may be necessary for you to consult a lawyer in another jurisdiction. We would be pleased to assist you with seeking counsel in another jurisdiction.

Client Information Part 1

1. Information About You

Full Name

Prefix First Middle Last

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Date of Birth

Marital Status

( including plans to marry )

Phone [Home]

Phone [Alt]

Fax [Home]

Fax [Alt]

Mail/fax to be sent to:

Home
Work

Telephone before faxing?

Yes
No

2. Information About Your Spouse

Full name of spouse

Prefix First Middle Last

Other names your spouse/partner is or has been known by

Occupation

(if retired, also include former occupation)

Date of Birth

Your marriage is

A legal marriage
A common law marriage

3. Other Personal Relations

Are you now cohabiting with someone other than a person to whom you are legally married:

Yes
No

Name

4. Your Children

The word “child” includes a child of your marriage, a child born outside of marriage, and an adopted child. Please provide the following information for each of your children and y our spouse or partner’s children.

Children:

Name	Age	Address	Is the Child yours? Spouse's? Or from this Marriage?	Actions

There are no Entries.

5. Your Health Care Providers

Name and phone number of your doctor(s):

May we have your permission to contact your doctor(s)?

Yes
No

Please provide us with the names and phone numbers of any other person who we should contact for information about you:

6. If the Client is incapable of providing detailed information, who is providing it?

Name

Prefix First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to the client:

Occupation

Phone [Home]

Phone [Alt]

Fax [Home]

Fax [Alt]

Mail/Fax to be sent to:

Home
Work

Telephone before faxing?

Yes
No

7. Using the Representation Agreement

When do you anticipate using the Representation Agreement, and why?

Representation Agreement Questionnaire

Client Information Part 1

1. Information About You

2. Information About Your Spouse

3. Other Personal Relations

4. Your Children

5. Your Health Care Providers

6. If the Client is incapable of providing detailed information, who is providing it?

7. Using the Representation Agreement

Client Information Part 2

1. Health Care Representatives

2. Your Monitor

3. Health or Personal Care Decisions

4. Term of the Agreement

5. Location of the Agreement

6. Living Will

7. Enduring Power of Attorney

8. Nomination of Committee

KMK LAW CORPORATION

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