The Guardianship Act states who can give substitute consent to medical or dental treatment for a patient 16 years or over who is unable to give a valid consent themselves. For most treatments a particular person, identified in the Act, will be able to give a valid consent on the patient's behalf. This person is called the 'person responsible' and is not necessarily the 'next of kin'.
Refer to the chart to decide if there is a 'person responsible' and whether that person can consent to the proposed treatment or whether the Guardianship Tribunal's consent will be necessary.
This Plain Web format version of the form is for information purposes only. To complete this, print out the accompanying PDF version of this form, complete the PDF version and then send it to the Guardianship Tribunal.
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Reason for seeking consent from the Guardianship Tribunal
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An application to the Guardianship Tribunal for consent
is usually only required in the following circumstances.
Tick which of these apply to this application. See
Summary Guide.
[ ] 'major' treatment and there is no 'person
responsible' for the patient
[ ] 'major' treatment and person responsible can't be
located or is unwilling to consent
[ ] there is dispute about the treatment
[ ] the patient objects to the treatment
[ ] the treatment is a 'special' medical treatment
[ ] the treatment is 'experimental'
[ ] other reason
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Patient - person who is unable to consent
(please print clearly)
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NAME: Mr/Mrs/Ms/Miss/Dr:
_________________________________________________________
Given names:
_________________________________________________________
Family name:
_________________________________________________________
ADDRESS:
_________________________________________________________
_________________________________________________________
Postcode:
_________________________________________________________
TELEPHONE: Daytime:
_________________________________________________________
After hours:
_________________________________________________________
Fax:
_________________________________________________________
Date of birth:
_________________________________________________________
Has the treatment been discussed with this person?
[ ] yes
[ ] no
Is it your opinion that the patient is unable to
understand the general nature and effect of the
proposed treatment or is unable to indicate their
consent to the treatment?
[ ] yes
[ ] no
[ ] don't know
In your opinion what is the reason for the patient's
inability to understand or indicate their understanding
of the treatment proposed, for example unconsciousness,
dementia, intellectual disability:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
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Person requesting consent (please print clearly)
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NAME: Mr/Mrs/Ms/Miss/Dr:
_________________________________________________________
Given names:
_________________________________________________________
Family name:
_________________________________________________________
ADDRESS:
_________________________________________________________
_________________________________________________________
Postcode:
_________________________________________________________
TELEPHONE: Daytime:
_________________________________________________________
After hours:
_________________________________________________________
Fax:
_________________________________________________________
Your Relationship to the patient for example parent, GP:
_________________________________________________________
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Doctor/dentist carrying out the treatment (if not
yourself) (please print clearly)
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NAME: Mr/Mrs/Ms/Miss/Dr:
_________________________________________________________
Given names:
_________________________________________________________
Family name:
_________________________________________________________
Qualifications/speciality:
_________________________________________________________
Practice address:
_________________________________________________________
_________________________________________________________
Postcode:
_________________________________________________________
TELEPHONE: Daytime:
_________________________________________________________
After hours:
_________________________________________________________
Fax:
_________________________________________________________
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Proposed treatment
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What is the condition requiring treatment?
_________________________________________________________
_________________________________________________________
What is the proposed treatment?
_________________________________________________________
_________________________________________________________
If the treatment is ongoing, for what period of time is
consent requested?
_________________________________________________________
_________________________________________________________
Does the treatment involve any significant risk or side
effects? If so, please list and explain.
_________________________________________________________
_________________________________________________________
Are there reasonable alternative treatments for the
condition? If so, list these, describe any associated
risks and side effects and briefly explain why the
proposed treatment is preferred.
_________________________________________________________
_________________________________________________________
Explain the likely consequences if the proposed treatment
is not carried out.
_________________________________________________________
_________________________________________________________
What other medication (include dosage)/treatment is the
patient receiving?
_________________________________________________________
_________________________________________________________
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Patient's views
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In your opinion does the patient have any understanding
of what the treatment entails? Please explain.
_________________________________________________________
_________________________________________________________
Has the patient indicated any views about the treatment
now or in the past? If so, what are these?
_________________________________________________________
_________________________________________________________
Does the patient object to the proposed treatment?
[ ] yes
[ ] no
If yes, what is the nature of the patient's objection?
_________________________________________________________
_________________________________________________________
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Person responsible (refer to chart) (please print clearly)
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Is there a 'person responsible' for the patient?
If YES, who is this?
NAME: Mr/Mrs/Ms/Miss/Dr:
_________________________________________________________
Given names:
_________________________________________________________
Family name:
_________________________________________________________
ADDRESS:
_________________________________________________________
_________________________________________________________
Postcode:
_________________________________________________________
TELEPHONE: Daytime:
_________________________________________________________
After hours:
_________________________________________________________
Fax:
_________________________________________________________
Relationship to patient:
_________________________________________________________
This application will be considered at a hearing of the
Guardianship Tribunal. The Tribunal will want to speak
with the applicant and others involved. Usually this
will be by phone. Some applications, particularly for
special and experimental treatments, will require more
information and may require attendance at a hearing.
A staff member will contact applicants if this is
necessary.
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Time and place of treatment (please print)
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The Tribunal must know when consent is needed so an
appropriate hearing time can be arranged.
When is the treatment due to commence or be carried out?
Date:
_________________________________________________________
Approximate time (am/pm):
_________________________________________________________
Place of treatment:
_________________________________________________________
If the treatment is an ongoing treatment which is
already being carried out, when did it begin?
_________________________________________________________
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You must sign and date this application
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Signature of person completing form:
_________________________________________________________
Date:
_________________________________________________________
Name (please print)
_________________________________________________________
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Who is the 'person responsible'?
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If there is no-one in the first category, go to the
second and so on.
1. A guardian who has the function of consenting to
medical, dental and health care treatments.
2. Spouse or de facto spouse where there is a close,
continuing relationship.
3. Carer where the carer provides or arranges for
domestic support on a regular basis and is unpaid.
(If the person is in residential care, then the
carer before the person went into residential care.)
4. Close personal friend or close relative where there
is both a close personal relationship, frequent
personal contact and a personal interest in the
patient's welfare, on an unpaid basis.
If a person identified as being a 'person responsible'
declines in writing to exercise the function of
'person responsible' or a medical practitioner or
other qualified person certifies in writing that the
person identified as 'person responsible' is not
capable of carrying out those functions, then the
person next in the hierarchy is the 'person responsible'.
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SUMMARY GUIDE TO MEDICAL AND DENTAL CONSENT
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for adults, 16 years and over, who cannot consent for
themselves
URGENT TREATMENT
INCLUDES:
Urgently necessary to:
• save patient's life
• prevent serious damage to health
• prevent or alleviate significant pain or distress
WHO CAN CONSENT:
No consent needed
MINOR TREATMENT
INCLUDES:
All medical and dental treatments (except those listed
in MAJOR or SPECIAL) includes:
• treatment involving general anaesthetic or other
sedation
• for management of fractured or dislocated limbs
• for endoscopes inserted through an orifice, not
penetrating the skin
• medications that affect the central nervous system
• when used for analgesic, antipyretic,
antiparkinsonian, antihistaminic, antiemetic,
antinauseant or anticonvulsant purposes
• PRN not more than 3 times per month
• sedation in minor procedures
• when such medications are used only once
WHO CAN CONSENT:
'Person responsible can consent. If no 'person
responsible' or 'person responsible' cannot be located
or cannot/will not respond and patient is not objecting,
the doctor or dentist may treat without consent. They
must note on patient's record that the treatment is
necessary to promote the patient's health and wellbeing
and that the patient is not objecting.
MAJOR TREATMENT
INCLUDES:
• Any medical or dental treatment involving general
anaesthetic (except as listed in MINOR above)
• Central nervous system affecting medications (except
as listed in MINOR above)
• Most drugs of addiction (except as listed in SPECIAL
below)
• Long acting injectable hormonal substances for
contraception or menstrual regulation
• Any treatment for the purpose of eliminating
menstruation
• Testing for HIV
• Any treatment involving substantial risk
• Any dental treatment resulting in removal of all
teeth or significantly impairing ability to chew food
WHO CAN CONSENT
'Person responsible' can consent. If no 'person
responsible' (or if cannot be located or can't/won't
respond), then only the Guardianship Tribunal can
consent.Request and consent must be in writing or, if
not practicable, later confirmed in writing.
SPECIAL
INCLUDES:
• Sterilisation (includes vasectomy and tubal
occlusion)
• Termination of pregnancy
• Drugs of addiction used for more than 10 days in 30,
except when used to treat cancer or palliative care
of terminally ill patients
• Aversives - mechanical, chemical or physical
• Experimental treatments:
• any new treatment that has not yet gained the
support of a substantial number of doctors or
dentists specialising in area
• use of central nervous system affecting medication
where dosage, duration or combination is outside
accepted norms
• androgen reducing medications for behavioural
control
WHO CAN CONSENT
Only the Guardianship Tribunal can consent.
OBJECTIONS TO NON-URGENT TREATMENT
INCLUDES:
If the patient or the 'person responsible' indicates,
or has previously indicated, that he or she does
not want the treatment carried out
WHO CAN CONSENT
Only the Guardianship Tribunal can consent.
Address: 2a Rowntree Street, Balmain, NSW, 2041
Postal Address: Locked Mailbag 9, Balmain NSW 2041
Phone: (02) 9555 8500
Fax: (02) 9555 9049
Tollfree: 1800 463 928
Email: gt@gt.nsw.gov.au
Website: www.gt.nsw.gov.au