1. Special Medical Conditions: Section to be included when patient has specific medical conditions requiring special attention or care instructions

2. Religious or Cultural Preferences: To be included when specific religious or cultural considerations affect medical treatment decisions

3. Mental Capacity Statement: Required when the patient has diminished mental capacity, including relevant medical assessments and legal declarations

4. Multiple Caregiver Hierarchy: To be included when multiple caregivers are designated with different levels of decision-making authority

5. Revocation Clause: Optional section detailing the process for revoking or modifying the permission, particularly relevant for longer-term arrangements

1. Schedule A - Specific Medical Procedures: Detailed list of specific medical procedures or treatments that are explicitly permitted or prohibited

2. Schedule B - Medical History Summary: Brief summary of relevant medical history, current medications, and allergies

3. Schedule C - Healthcare Facility List: List of preferred or approved healthcare facilities where the permission form is intended to be used

4. Appendix 1 - Identity Documents: Copies of identity documents of patient and caregiver(s) to be attached

5. Appendix 2 - Supporting Medical Documents: Any relevant medical certificates, doctor's notes, or capacity assessments