- Part 3 of 4 -

Patient Advocate Agreement

A patient advocate agreement can help you and your advocate decide how your advocate can best provide you with the support you need. Please read through this information and fill out the form at the bottom of this page.

For tips on advocating for yourself and others go to: www.safetoask.ca and www.mips.ca

Endorsed by:
CancerCare Manitoba - Interlake-Eastern Regional Health Authority - Northern Health Region - Prairie Mountain Health - Southern Health-Santé Sud - Winnipeg Regional Health Authority

Instructions to Patient:
1. Discuss the information with your advocate(s) before you complete this agreement.
2. Complete and sign the agreement.
3. Have your patient advocate sign this agreement. 
4. This form will be submitted to Daughter On Call and we will add it to your file.
5. Review this agreement from time to time as your wishes may change.

Patient Advocate Agreement

Please fill this out with your Advocate.

I give permission to my patient advocate to do the following (Check as many as you wish):

Disclaimer
The information in this agreement is given to help you. It is not professional legal or medical advice. The Manitoba Institute for Patient Safety is not responsible for any loss, damage, or injury arising from a person acting as a patient advocate, or a person using the information on this document or the website (www.mips.ca).


Signing this agreement means that we have read the entire agreement, including the frequently asked questions and answers, and we accept this disclaimer.

Thank you for filling out this form.