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    Government of Yukon

    Health and Social Services

    A to Z forms

     Environmental Health Services

     Environmental Health Services Survey
             English French PDF (YG5984)

     Food Vending Vehicle - Application-Checklist for a Permit to Operate
             English French PDF (YG5922)

     Privy - Application for Authorization to Construct, Install and/or use a Privy
             Bilingual PDF (YG5438)

     Sampling Site Information Form
             Bilingual PDF (YG5777)

     Septic Tank and Sewage Holding Tank Installation Declaration
             English French PDF (YG5742)

     Septic Tank and Soil Absorption System - Notification of Installation/Maintainence
             English French PDF (YG4674)

     Sewage Disposal System - Application for Approval to Use
             English French PDF (YG5964)

     Sewage Disposal System - Application for Permission to Retain
             English French PDF (YG5073)

     Sewage Disposal System - Application for a Permit to Install
             English French PDF (YG4307)

     Sewage Disposal System - Photographic Submission of Installation
             English French PDF (Guidelines)

     Sewage Disposal System - Evidence Requirements for Approval to Use
             English French PDF (YG5965)

     Sewage Disposal System - Notification of Abandonment and Reclamation
             English French PDF (YG5589)

     Sewage Holding Tank - Electrical Assurance
             English French PDF (YG6325)

     Sewage Holding Tank - Notification of Installation/Maintainence
             English French PDF (YG4673)

     Sewage Pump-Up Systems - Electrical Assurance
             English French PDF (YG6326)


     Insured Health

     Hearing Screening Consent Form – Student
             English French PDF (YG6486)

     Out-of-Country Claims
             English French PDF (YG6473)


     Mental Health Act

     Form 1 - Application for Order for Involuntary Examination
             English French PDF (YG3983)

     Form 2 - Order to Apprehend
             English French PDF (YG3984)

     Form 3 - Statement of Peace Officer on Apprehension
             English French PDF (YG3985)

     Form 4 - Reccomendation for Involuntary Psychiatric Assessment (Physician)
             English French PDF (YG3986)

     Form 5 - Recommendation for Involuntary Psychiatric Assessment (Nurse)
             English French PDF (YG3987)

     Form 6 - Patient's Right to be Informed
             French English PDF (YG4077)

     Form 7 - Certificate of Involuntary Admission
             English French PDF (YG3989)

     Form 8 - Waiver of Right to an Automatic Hearing
             French English PDF (yg5281)

     Form 9 - Application to the Capability and Consent Board
             French English PDF (yg3988)

     Form 10 - Authorization for Specified Treatment
             French English PDF (yg3996)

     Form 11 - Certificate of Renewal of Involuntary Admission
             French English PDF (yg3997)

     Form 12 - Certificate of Change of Status
             French English PDF (yg3998)

     Form 13 - Notice of Intention to Transfer an Involuntary Patient (Yukon Resident)
             French English PDF (yg3990)

     Form 14 - Renewal of Proposed Patient Transfer
             French English PDF (yg4000)

     Form 15 - Application for Transfer of a Non-Resident Involuntary Patient
             French English PDF (yg4002)

     Form 16 - Temporary Release of Involuntary Patient
             French English PDF (yg4003)

     Form 17 - Certificate of Return
             French English PDF (yg4004)

     Form 18 - Application to Withhold Clinical Record
             French English PDF (yg4005)

     Form 19 - Request for Correction of the Clinical Record
             French English PDF (yg4006)

     Form 20 - Statement of Disagreement with a Clinical Record
             French English PDF (yg4007)

     Form 21 - Consent of Disclosure, Transmittal or Examination of a Patient Record
             French English PDF (yg4008)


     Mental Wellness and Substance Use Services

     Referral Information Sheet
             English French PDF (YG1552)


     Referred Care Clinic

     Consent for Release of Information
             English French PDF (YG6523)

     Initial Assessment
             English French PDF (YG6524)

     Medication Agreement
             English French PDF (YG6522)

     Pharmacy Agreement
             English French PDF (YG6526)


     Vital Statistics

     Birth, Marriage, or Death Certificate - Application or Search
             English French PDF (YG3385)

     Change of Name: Application for Adult
             Bilingual PDF (YG3401)

     Change of Name: Application for Dependant Children
             Bilingual PDF (YG3404)

     Change of Sex on Registration - Over 16 Years
             English French PDF (YG6471)

     Change of Sex on Registration - Under 16 Years
             English French PDF (YG6470)

     Marriage Commissioner Application Form
             English French PDF (YG6102)


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