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{{REVIEWEDPLS | reviewer = Sarah Watson and Karl Maier, [http://www.trustee.bc.ca/  Public Guardian and Trustee of British Columbia]|date= June 2018}} {{Dial-A-Law TOC|expanded = health}}
Generally speaking, adults can only be given health care with their '''consent'''. We explain consent, and the exceptions to this general rule, including what happens when someone is mentally incapable.


{{Dial-A-Law TOC|expanded = health}}
==What you should know==
Do you have the right to refuse healthcare? What law allows doctors to treat you if you’re unconscious or unable to indicate what medical treatment you want? The answers to these and other questions are in a BC law called the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01 Health Care (Consent) and Care Facility (Admission) Act]''.


This Act applies to adults—people 19 and over—but not to children. It also applies to the healthcare (but not the psychiatric care) of people who are involuntarily admitted to hospital for psychiatric treatment under the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/96288_01 Mental Health Act]''. For information on consenting to and refusing psychiatric treatment as an involuntary patient, check script [[Hospitalizing a Mentally Ill Person (Script 425)|425]], called “Hospitalizing a Mentally Ill Person”. For the law on children and consent to healthcare, check script [[Children and Consent to Health Care (Script 422)|422]], called “Children and Consent to Healthcare”.
===Adults can only be given health care with their consent===
The general rule [https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec5_smooth under the law in BC] is: a doctor (or another health care provider) can treat you only if you '''consent'''.


==A doctor or healthcare provider can treat you only if you give valid consent==
For this rule to apply, you must be a '''mentally capable adult'''. Different rules apply to children; see [[Children and Consent to Health Care|children and consent to health care]]. If an adult is unconscious, mentally incapable, or otherwise unable to give consent, the law sets out procedures to follow. We explain those shortly.
For your consent to be valid, you must be informed. That means your doctor or healthcare provider must explain your illness or condition to you and tell you about the proposed treatment, the risks and benefits of it, and any alternative treatments, including no treatment.


The law says, “Consent to health care may be expressed orally or in writing or may be inferred from conduct”. This means that people can consent to healthcare in writing or verbally. And if a person can’t give written or verbal consent, a doctor or healthcare provider may be able to decide—based on the person’s conduct—that the person consents to healthcare.
For your consent to be valid, it must be '''informed'''. This means your doctor or health care provider must explain your illness or condition to you and tell you about the proposed treatment, the risks and benefits of it, and any alternative treatments, including no treatment.


==Do you have the right to refuse healthcare?==
Consent to health care may be given “orally or in writing or may be inferred from conduct.” This means there are three ways you can give consent:
Yes. Every capable adult has the right to consent to healthcare or refuse it—for any reason, including moral and religious reasons. Adults also have the right to change their decisions about medical treatment. You can refuse life support or other healthcare, such as a blood transfusion, even if it means you will die.


To refuse treatment, you must be mentally capable of making that decision. The law presumes all adults are capable of giving, refusing, or revoking their consent, unless it’s clear they are not capable of making those decisions. If a doctor questions a person’s mental capability, the doctor can require the person to have a capacity assessment performed by a medical expert.
# you can give consent verbally,
# you can give consent in writing, or
# a health care provider can decide, based on your conduct, that you consent to health care.


==What if you’re incapable and cannot consent?==
{| class="wikitable"
Consent to healthcare in a medical emergency may not be needed to treat you if you’re an adult—it depends on the situation. If your life or health is seriously threatened, and it appears that you are not capable of making healthcare decisions, healthcare providers may not need consent to treat you. Because they are dealing with a medical emergency, they may do whatever is necessary to try to save your life or prevent serious physical or mental harm.  
|align="left"|'''Tip'''
For information on consenting to and refusing psychiatric treatment as an involuntary patient, [[Hospitalizing a Mentally Ill Person|see our information on hospitalizing a mentally ill person]].
|}


But healthcare providers must not provide healthcare to you if you become incapable and they have reasonable grounds to believe that you previously indicated that you wanted to refuse healthcare in a particular situation—even a medical emergency. For example, if you carry a card saying you refuse to have a blood transfusion, and the healthcare provider sees that card, they must respect your wishes.  
===You have the right to refuse health care===
Every adult who is capable has the right to give consent or to refuse consent to health care for any reason, including moral or religious reasons. You can refuse life support or other health care, such as a blood transfusion, even if it means you will die. You also have the right to change your decision.


==Advance directives—what are they and how do they work?==
To refuse treatment, you must be '''mentally capable''' of making that decision. The law presumes all adults are capable of giving, refusing, or revoking their consent, unless it’s clear they are not capable of making those decisions. If a doctor questions a person’s mental capability, the doctor can require the person to have a capacity assessment performed by a medical expert.
If you previously indicated what you want in a medical emergency, healthcare providers must follow your wishes in an emergency. For example, you may have made a legal document called an '''[http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01#part2.1 advance directive]'''. That is a written instruction by a capable adult that gives or refuses consent to healthcare (described in the advance directive) if the adult is not capable of giving the instruction when the healthcare is needed.  


'''Signing requirements'''—an advance directive must be signed and dated by the adult in front of 2 witnesses. The directive must also be signed and dated by the 2 witnesses in front of the adult (only one witness is needed if the person is a notary or lawyer). Both witnesses must be capable adults who understand the type of communication the adult uses. They can use an interpreter if necessary.
===Exception in a medical emergency===
In a '''medical emergency''', a health care provider may not need your consent to provide health care. If you are unconscious or otherwise incapable of giving consent, a health care provider may do whatever is necessary to try to save your life or prevent serious harm.


'''Who cannot be a witness'''—the following people cannot be a witness:
This medical emergency exception does not apply if a representative who is authorized to consent to health care for you is available.
:a) a person who provides personal care, healthcare or financial services to the adult for compensation, other than a lawyer or notary.
:b) a spouse, child, parent, employee, or agent of a person described in paragraph (a).
:c) a person who is not an adult.
:d) a person who does not understand the type of communication used by the adult.


'''Signing for an adult who is not physically capable'''—if an adult is not physically capable of signing an advance directive, another person can sign it for them if the adult is physically present and directs the person to sign the directive. Their signature must be witnessed as if the adult were signing the directive. The following people must not sign an advance directive for an adult:
As well, the medical emergency exception does not apply if the health care provider has reasonable grounds to believe that you, while a capable adult, expressed a wish to refuse health care in a particular situation. For example, if you carry a card saying you refuse to have a blood transfusion, and the health care provider sees that card while treating you in a medical emergency, they must respect your wishes.
:a) a witness to the signing of the advance directive.
:b) a person prohibited from acting as a witness (described in the preceding paragraph).


Even if an advance directive is not properly witnessed, it may still show an adult’s wishes when they were capable. So it may still be a guide for the person who must make the healthcare decision.
===An advance directive gives written instructions about health care wishes===
If you previously indicated what health care you want (or don’t want) in a medical emergency, health care providers must follow your wishes in an emergency. For example, [https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec19.1_smooth you can make a legal document called an '''advance directive''']. This is a written instruction about what health care you want or do not want in the future if a decision needs to be made and you’re incapable of making it.


If a healthcare provider knows there is an advance directive that applies to the proposed healthcare and there is no committee (script [[Committeeship (Script 426)|426]]) or representative (script [[Power of Attorney and Representation Agreements (Script 180)|180]]) with authority to make decisions for the adult, the healthcare provider must follow the advance directive for the proposed healthcare.
====Signing requirements====
An advance directive has [https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec19.1_smooth requirements on how it is signed and witnessed]. It must be signed and dated by the adult making the advance directive, in front of two witnesses. It must also be signed and dated by the two witnesses in front of the adult. (Only one witness is needed if the witness is a notary public or lawyer.) Both witnesses must be capable adults who understand the type of communication the adult uses. They can use an interpreter if necessary.


But an advance directive does not apply in any of the following cases:
Certain people are not able to witness an advance directive. For example, a person can’t be a witness if they provide personal care, health care, or financial services to the adult for compensation (there is an exception for a lawyer or notary public).
*if the healthcare provider believes that the directive does not cover the healthcare decision to be made, or if it is too vague to tell if the adult has given or refused consent to the healthcare.
*if, after the advance directive was made, the adult’s wishes, values, or beliefs in relation to the healthcare decision have changed, and the advance directive does not reflect the change.
*if, after the advance directive was made, significant changes in medical knowledge, practice, or technology have been made that might substantially benefit the adult in relation to healthcare.


‘’‘Temporary substitute decision-makers’‘’—in some cases, another person can make medical decisions for you if you’re too ill or otherwise unable to decide. If you’ve made a representation agreement allowing your representative to make all major and minor health decisions for you, your representative can make the medical decision. Script [[Power of Attorney and Representation Agreements (Script 180)|180]], called “Power of Attorney and Representation Agreements” has more on this. If you’re mentally incapable, a person appointed by the court as a committee (pronounced comm-it-tay) of the person can make medical decisions for you. Script [[Committeeship (Script 426)|426]], called “Committeeship” has more on this.  
If an adult is not physically capable of signing an advance directive, another person can sign it for them if the adult is physically present and directs the person to sign the directive. Certain people can’t sign an advance directive for an adult, including a witness to the signing or someone who can’t witness an advance directive.


But if you have no representative or committee of the person, your healthcare provider must choose a '''[http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01#section16 temporary substitute decision-maker]''', or '''decision-maker''', based on what the Act requires, as the next section explains.
Even if an advance directive is not properly witnessed, it may still show an adult’s wishes when they were capable. So it may still be a guide for the person who must make the health care decision.
 
====Effect of an advance directive====
Generally speaking, if an adult needs health care and is incapable of giving or refusing consent to the health care — and the health care provider doesn’t know of any representative or committee with authority to make decisions for the adult — then the health care provider must follow any advance directive they are aware of.
 
But there are exceptions. A health care provider does '''not''' have to follow the instructions in an advance directive if they reasonably believe any of these things:
 
* The advance directive does not cover the health care decision to be made.
* The instructions in the directive are so unclear it can’t be determined whether the adult has given or refused consent to the health care.
* Since the advance directive was made, the adult’s wishes, values or beliefs in relation to the health care decision significantly changed, and the advance directive does not reflect the change.
* Since the advance directive was made, there have been significant changes in medical knowledge, practice or technology that might substantially benefit the adult in relation to health care covered by the directive.
 
===If you’re too ill or otherwise unable to make health care decisions===
In some cases, another person can make health care decisions for you if you’re too ill or otherwise unable to decide.
 
You may have made a '''representation agreement''' allowing your '''representative''' to make health care decisions for you. [[Powers of Attorney and Representation Agreements|We have information on representation agreements]]. If you become mentally incapable, a court may appoint a person as your '''committee''', and that person can make health care decisions for you. [[Committeeship|We explain committeeship]].
 
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec16_smooth Under the law in BC], if you have neither a representative nor a committee, and you are too ill or otherwise unable to make a decision on your health care, your health care provider must choose a '''temporary substitute decision-maker''' based on a priority order set out in the law.
 
===How a temporary substitute decision-maker is chosen===
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec16_smooth Under the law in BC], your health care provider, in choosing a '''temporary substitute decision-maker''', must ask people in the following order:


==How is a decision-maker chosen?==
Your healthcare provider, in choosing a decision-maker, must ask people in the following order (from the Act):
# your spouse or partner (including a same-sex partner)
# your spouse or partner (including a same-sex partner)
# an adult child
# an adult child
Line 60: Line 75:
# a close friend
# a close friend
# a person immediately related by marriage
# a person immediately related by marriage
# the Public Guardian and Trustee*
# the Public Guardian and Trustee
 
A decision-maker must be at least 19 years old, be mentally capable, and have no dispute with you. They must also have been in contact with you in the past 12 months.


* If no one on this list is available or qualifies to be a decision-maker, or if there’s a dispute about who the decision-maker should be, the healthcare provider must choose the Public Guardian and Trustee (or a person it chooses) to be the decision-maker.
If no one on this list is available or qualifies to be a decision-maker, or if there’s a dispute about who the decision-maker should be, the health care provider must choose the Public Guardian and Trustee (or a person it chooses) to be the temporary substitute decision-maker.


==What kind of decisions can a decision-maker make?==
A temporary substitute decision-maker must be at least 19 years old, be mentally capable, and have no dispute with you. They must also have been in contact with you in the past 12 months.
A decision-maker can make decisions about any kind of healthcare, except controversial or irreversible treatments such as organ transplants and experimental surgery. [http://www.bclaws.ca/civix/document/id/complete/statreg/20_2000#section5 Section 5] of the ''[http://www.bclaws.ca/civix/document/id/complete/statreg/20_2000 Health Care Consent Regulation says a decision-maker cannot consent to those types of healthcare]''.  


[http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01#section18 Section 18(2) of the Act] allows a decision-maker to say no to life-saving treatment if you’re terminally ill or critically injured and your doctor will follow their decision. But the doctor may challenge the decision if it is medically inappropriate and there’s no evidence that the decision reflects your wishes and is in your best interests.  
===The role of a temporary substitute decision-maker===
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec18_smooth Under the law in BC], a person chosen to be a temporary substitute decision-maker can make decisions about any kind of health care, except controversial or irreversible treatments such as organ transplants or experimental surgery.


==What are the duties of a decision-maker?==
A temporary substitute decision-maker can say no to life-saving treatment if you’re terminally ill or critically injured, but only if there is substantial agreement among the health care providers caring for you that the decision is medically appropriate and reflects your wishes or is in your best interests.
A decision-maker must consult with you if possible. If that’s not possible, they must follow any directions you gave while you were capable. You should let your family know now what decisions you would like if you can no longer decide for yourself. If your wishes are unknown, a decision-maker must give or refuse consent in your best interests, considering whether:
*your condition will improve with the proposed healthcare.
*the condition will improve without the healthcare.
*the benefit of the healthcare is greater than the risk of harm.
*less restrictive or less intrusive healthcare would be as helpful as the proposed healthcare.


==What if someone disagrees with a decision-maker?==
A temporary substitute decision-maker must consult with you if possible. If that’s not possible, they must follow any directions you gave while you were capable. You should let your family know now what decisions you would like if you can no longer decide for yourself. If your wishes are unknown, a decision-maker must give or refuse consent in your best interests, considering whether:
If a friend, family member, or doctor is concerned about any major healthcare decision by a decision-maker, they can ask the health authority to review the decision. Each health authority is supposed to have a dispute resolution process.


==Applying to court in certain cases==
* your condition will improve with the proposed health care
Under [http://www.bclaws.ca/civix/document/id/complete/statreg/96181_01#section33.4 Section 33(4) of the Act], the following people can apply to court for orders about certain things:
* the condition will improve without the health care
*a healthcare provider caring for an adult incapable of giving or refusing consent to healthcare.
* the benefit of the health care is greater than the risk of harm
*an adult's representative or personal guardian.
* less restrictive or less intrusive health care would be as helpful as the proposed health care
*a decision-maker.
*an adult assessed as incapable of giving or refusing consent to healthcare or admission to a care facility.


The court can:
===If someone disagrees with a temporary substitute decision-maker===
# give direction on an advance directive, or any other healthcare instruction or wish.
If a friend, family member, or doctor is concerned about any major health care decision by a temporary substitute decision-maker, they can ask the health authority to review the decision. Each health authority in the province is required to have a dispute resolution process.
# say who the decision-maker should be.
# confirm, reverse, or change a decision of a representative, guardian, or decision-maker.
# order the adult to have an assessment of incapability.
# make any decision that a person chosen to give substitute consent under the Act could make.


==More information==
[https://www.canlii.org/en/bc/laws/stat/rsbc-1996-c-181/latest/rsbc-1996-c-181.html#sec33.4_smooth Under the law in BC], certain people can apply to court to challenge a decision by a temporary substitute decision-maker to give or refuse consent to health care. Those who can apply to court include a health care provider or the adult themselves (that is, the person who has been assessed as incapable of giving or refusing consent to health care).
To learn more about consenting to—and refusing—healthcare, call the Public Guardian and Trustee of BC at 604.775.1007 in Vancouver, 604.775.1001 in the lower mainland, and 1.877.511.4111 elsewhere in BC (the call is free). Also, check the [http://www.trustee.bc.ca/ Public Guardian and Trustee website] and the [http://www.gov.bc.ca/health Ministry of Health website].


Under this same law, the court can be asked to say who the temporary substitute decision-maker should be.


[updated June 2018]
==Who can help==


'''The above was last edited by John Blois.'''
===With more information===
The '''Public Guardian and Trustee'''’s website provides information about consenting to and refusing health care.


----
* Call 604-775-1001 (Lower Mainland) or 1-877-511-4111 (toll-free)
----
* [http://www.trustee.bc.ca/ Visit website]


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Latest revision as of 00:50, 8 October 2020

This information applies to British Columbia, Canada. Last reviewed for legal accuracy by Sarah Watson and Karl Maier, Public Guardian and Trustee of British Columbia in June 2018.

Generally speaking, adults can only be given health care with their consent. We explain consent, and the exceptions to this general rule, including what happens when someone is mentally incapable.

What you should know

Adults can only be given health care with their consent

The general rule under the law in BC is: a doctor (or another health care provider) can treat you only if you consent.

For this rule to apply, you must be a mentally capable adult. Different rules apply to children; see children and consent to health care. If an adult is unconscious, mentally incapable, or otherwise unable to give consent, the law sets out procedures to follow. We explain those shortly.

For your consent to be valid, it must be informed. This means your doctor or health care provider must explain your illness or condition to you and tell you about the proposed treatment, the risks and benefits of it, and any alternative treatments, including no treatment.

Consent to health care may be given “orally or in writing or may be inferred from conduct.” This means there are three ways you can give consent:

  1. you can give consent verbally,
  2. you can give consent in writing, or
  3. a health care provider can decide, based on your conduct, that you consent to health care.
Tip

For information on consenting to and refusing psychiatric treatment as an involuntary patient, see our information on hospitalizing a mentally ill person.

You have the right to refuse health care

Every adult who is capable has the right to give consent or to refuse consent to health care for any reason, including moral or religious reasons. You can refuse life support or other health care, such as a blood transfusion, even if it means you will die. You also have the right to change your decision.

To refuse treatment, you must be mentally capable of making that decision. The law presumes all adults are capable of giving, refusing, or revoking their consent, unless it’s clear they are not capable of making those decisions. If a doctor questions a person’s mental capability, the doctor can require the person to have a capacity assessment performed by a medical expert.

Exception in a medical emergency

In a medical emergency, a health care provider may not need your consent to provide health care. If you are unconscious or otherwise incapable of giving consent, a health care provider may do whatever is necessary to try to save your life or prevent serious harm.

This medical emergency exception does not apply if a representative who is authorized to consent to health care for you is available.

As well, the medical emergency exception does not apply if the health care provider has reasonable grounds to believe that you, while a capable adult, expressed a wish to refuse health care in a particular situation. For example, if you carry a card saying you refuse to have a blood transfusion, and the health care provider sees that card while treating you in a medical emergency, they must respect your wishes.

An advance directive gives written instructions about health care wishes

If you previously indicated what health care you want (or don’t want) in a medical emergency, health care providers must follow your wishes in an emergency. For example, you can make a legal document called an advance directive. This is a written instruction about what health care you want or do not want in the future if a decision needs to be made and you’re incapable of making it.

Signing requirements

An advance directive has requirements on how it is signed and witnessed. It must be signed and dated by the adult making the advance directive, in front of two witnesses. It must also be signed and dated by the two witnesses in front of the adult. (Only one witness is needed if the witness is a notary public or lawyer.) Both witnesses must be capable adults who understand the type of communication the adult uses. They can use an interpreter if necessary.

Certain people are not able to witness an advance directive. For example, a person can’t be a witness if they provide personal care, health care, or financial services to the adult for compensation (there is an exception for a lawyer or notary public).

If an adult is not physically capable of signing an advance directive, another person can sign it for them if the adult is physically present and directs the person to sign the directive. Certain people can’t sign an advance directive for an adult, including a witness to the signing or someone who can’t witness an advance directive.

Even if an advance directive is not properly witnessed, it may still show an adult’s wishes when they were capable. So it may still be a guide for the person who must make the health care decision.

Effect of an advance directive

Generally speaking, if an adult needs health care and is incapable of giving or refusing consent to the health care — and the health care provider doesn’t know of any representative or committee with authority to make decisions for the adult — then the health care provider must follow any advance directive they are aware of.

But there are exceptions. A health care provider does not have to follow the instructions in an advance directive if they reasonably believe any of these things:

  • The advance directive does not cover the health care decision to be made.
  • The instructions in the directive are so unclear it can’t be determined whether the adult has given or refused consent to the health care.
  • Since the advance directive was made, the adult’s wishes, values or beliefs in relation to the health care decision significantly changed, and the advance directive does not reflect the change.
  • Since the advance directive was made, there have been significant changes in medical knowledge, practice or technology that might substantially benefit the adult in relation to health care covered by the directive.

If you’re too ill or otherwise unable to make health care decisions

In some cases, another person can make health care decisions for you if you’re too ill or otherwise unable to decide.

You may have made a representation agreement allowing your representative to make health care decisions for you. We have information on representation agreements. If you become mentally incapable, a court may appoint a person as your committee, and that person can make health care decisions for you. We explain committeeship.

Under the law in BC, if you have neither a representative nor a committee, and you are too ill or otherwise unable to make a decision on your health care, your health care provider must choose a temporary substitute decision-maker based on a priority order set out in the law.

How a temporary substitute decision-maker is chosen

Under the law in BC, your health care provider, in choosing a temporary substitute decision-maker, must ask people in the following order:

  1. your spouse or partner (including a same-sex partner)
  2. an adult child
  3. a parent
  4. a brother or sister
  5. a grandparent
  6. a grandchild
  7. anybody else related by birth or adoption
  8. a close friend
  9. a person immediately related by marriage
  10. the Public Guardian and Trustee

If no one on this list is available or qualifies to be a decision-maker, or if there’s a dispute about who the decision-maker should be, the health care provider must choose the Public Guardian and Trustee (or a person it chooses) to be the temporary substitute decision-maker.

A temporary substitute decision-maker must be at least 19 years old, be mentally capable, and have no dispute with you. They must also have been in contact with you in the past 12 months.

The role of a temporary substitute decision-maker

Under the law in BC, a person chosen to be a temporary substitute decision-maker can make decisions about any kind of health care, except controversial or irreversible treatments such as organ transplants or experimental surgery.

A temporary substitute decision-maker can say no to life-saving treatment if you’re terminally ill or critically injured, but only if there is substantial agreement among the health care providers caring for you that the decision is medically appropriate and reflects your wishes or is in your best interests.

A temporary substitute decision-maker must consult with you if possible. If that’s not possible, they must follow any directions you gave while you were capable. You should let your family know now what decisions you would like if you can no longer decide for yourself. If your wishes are unknown, a decision-maker must give or refuse consent in your best interests, considering whether:

  • your condition will improve with the proposed health care
  • the condition will improve without the health care
  • the benefit of the health care is greater than the risk of harm
  • less restrictive or less intrusive health care would be as helpful as the proposed health care

If someone disagrees with a temporary substitute decision-maker

If a friend, family member, or doctor is concerned about any major health care decision by a temporary substitute decision-maker, they can ask the health authority to review the decision. Each health authority in the province is required to have a dispute resolution process.

Under the law in BC, certain people can apply to court to challenge a decision by a temporary substitute decision-maker to give or refuse consent to health care. Those who can apply to court include a health care provider or the adult themselves (that is, the person who has been assessed as incapable of giving or refusing consent to health care).

Under this same law, the court can be asked to say who the temporary substitute decision-maker should be.

Who can help

With more information

The Public Guardian and Trustee’s website provides information about consenting to and refusing health care.

  • Call 604-775-1001 (Lower Mainland) or 1-877-511-4111 (toll-free)
  • Visit website
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