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.

Print this form

If you would rather complete this form on paper, we also offer a printable PDF version you can print, then mail or fax to us. (Details within)