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Medical Condition Consent Form

NOTE: Please complete this form only if the person with the life-threatening condition is not the account holder(s).

(Exactly as it appears on bill)
(12 Digits)
(optional, if applicable)
("The Premises")
(Optional)
*I am...
(choose all that apply)

*I hereby authorize the account holder (the "Account Holder") of the account with Hydro One Networks Inc. ("Hydro One") for the supply of electricity to the Premises where I live to disclose to Hydro One information pertaining to my life-threatening medical condition, including, but not limited to, delivering a Doctor’s Certificate from a physician stating that I have a life-threatening medical condition and depend on electrically powered medical equipment. Furthermore, I consent to Hydro One collecting from the Account Holder the said information and using it for the purposes of contacting the Account Holder in the event of a power outage that will affect the supply of electricity to the Premises.

I acknowledge that Hydro One will not be liable to anyone in the event that Hydro One is not able to or fails to contact the Account Holder for the Premises in the event of a power outage. I may revoke this consent at any time by notifying Hydro One in writing. I acknowledge that such revocation may result in Hydro One removing the Premises from its critical account list.