Government of Yukon

Health and Social Services

A to Z forms

 Adoption

 Cancel a Disclosure Veto or No-Contact Declaration
         English French PDF (YG5652)


 Dental Program Enrolment

 Consent for Examinations and Prevention Services
         English French PDF (YG4819)


 Emergency Information

 Emergency Information for Individuals with Complex Care Needs
         Bilingual PDF (YG6698)


 Environmental Health Services

 Consent to Release Information
         English French PDF (YG4684)

 Drinking Water - Permit to Operate a Large Public Drinking Water System
         English French PDF (YG5453)

 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)


 Housing and Community Outreach

 Application - HCOS Unit
         English French PDF (YG6546)


 Immunization

 Consent for School Immunizations - Grade 6
         English French PDF (YG5788)

 Consent for School Immunizations - Grade 9
         English French PDF (YG5838)


 Insured Health

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

 Hearing Services - Consent to Obtain Personal Health Information
         English French PDF (YG6529)

 Hearing Services - Consent to the Release of Personal Health Information
         English French PDF (YG6530)

 Organ Donor Registration
         English French PDF (YG6583)

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

 Temporary Absence
         English French PDF (YG3383)

 YHCIP Notice of Change
         Bilingual PDF (YG679)


 Medical Travel

 Out-of-Territory Medical Travel Subsidy Form
         English French PDF (YG4840)

 Out-of-Territory Medical Travel via Road to Scheduled Appointments
         English French PDF (YG4857)


 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)


 Palliative Care

 Consult Request
         English French PDF (YG6673)


 Public Health and Safety Act (For Doctors Only)

 Congenital Anomalies Surveillance Yukon (CASY) Referral Form
         English French PDF (YG5848)

 Congenital Anomalies Surveillance Yukon (CASY) - Child
         English French PDF (YG5914)

 Congenital Anomalies Surveillance Yukon (CASY) - Mother/Fetus
         English French PDF (YG5849)


 Rabies Protocol

 Rabies Risk Investigation Form ‘A’
         English PDF (YG5812)

 Rabies Risk Investigation Form ‘B’
         English PDF (YG5813)


 Record of User Activity

 Record of User Activity Request Form
         English French PDF (YG6379)

 Request for Access to Personal Information Records
         English French PDF (YG6364)


 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)


 Temporary Absence

 Temporary Absence
         English French PDF (YG3383)


 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)


 Whitehorse Emergency Shelter

 WES - Intake
         English French PDF (YG6717)