1. Specific Medical Conditions: Used when the grantor has specific medical conditions that require special consideration or instructions

2. Religious or Cultural Preferences: Include when the grantor has specific religious or cultural beliefs that should guide medical decisions

3. Geographic Limitations: Include when the proxy's authority is limited to specific jurisdictions or healthcare facilities

4. Additional Decision-Makers: Used when multiple proxy decision-makers need to be appointed with different levels of authority or for different types of decisions

5. Emergency Contacts: Optional section listing additional people to be contacted in emergencies, beyond the primary proxy

1. Schedule A - Medical Preferences: Detailed list of the grantor's preferences regarding specific medical treatments and procedures

2. Schedule B - Advance Care Directives: Specific instructions for end-of-life care and other critical medical situations

3. Schedule C - Healthcare Provider Information: List of current healthcare providers and relevant medical history

4. Appendix 1 - Capacity Assessment: If applicable, documentation confirming the grantor's mental capacity at the time of creating the proxy consent

5. Appendix 2 - Witness Attestations: Additional witness statements and declarations as required by provincial legislation