Consent for medical and dental treatment form

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Consent to carry out medical treatment for a person under the Guardianship of the Public Guardian (Guardianship and Administration Act 1995)

To avoid delays, it is recommended this form be completed at the time of scheduling the proposed treatment. Please provide at least two (2) business days notice before the proposed treatment when requesting consent.

When to use this form
Medical practitioners can use this form to apply for consent to carry out medical and dental treatment if the patient:

  • is unable to provide their own consent (even when supported),and
  • has the Office of the Public Guardian appointed to make medical and dental treatment decisions

Please note: consent provided on this form is only valid for 12 months from the date signed by the guardian.

Consent for treatment is not needed for minor and urgent matters (as per below):

Minor treatment
Section 3 of the Act allows for minor treatment to be administered without consent. This includes non-intrusive examinations, the administering of non-prescribed medications and first aid.

Urgent treatment
Section 40 of the Act allows for treatment to take place without consent under circumstances where the treatment will preserve life, prevent damage to a person’s health, and to prevent suffering.

1 Patient information
Date of birth *
2 Treating practitioner information
3 Patient views
3.1 Has the patient indicated whether or not they consent to the treatment?
3.2 In your opinion, is the patient able to understand the general nature of the proposed treatment?

Note: Yes to both indicates that the patient can provide consent and consent is not required from the Public Guardian.

Does the patient object to the proposed treatment?
4 Views of significant others
5 Proposed treatment
Date and time of proposed treatment *
Does this treatment require general anesthetic?
Note: if proposed treatment involves the use of anesthetics, please also include risks associated with these.
6 Attachments

If you are submitting attachment/s with your request, please include them in your email with this form.

If you are completing this form digitally from our website, please send attachments to public.guardian@publicguardian.tas.gov.au with a subject line indicating the attachments are to accompany a request for consent for medical and dental treatment.

7 Signature
Date *

Please print this completed form and send to public.guardian@publicguardian.tas.gov.au (including attachments if applicable).

For questions relating to consent or completing this form, please call 1800 955 772.

Office of the Public Guardian use only

I hereby consent to the above treatment.

Date *
Updated: 5 May 2026