**(A) Patient's Particulars**
**Name (in NRIC):** Tan Mei Ling
**NRIC/FIN/Passport:** S1958327D
**Date of Birth:** 14/03/1951
**LPA Reference No:** LPA-2019-061238
**(B) Doctor's Opinion on Patient's Mental Capacity**
**Diagnosis:**
Moderate to severe vascular dementia, diagnosed in 2024 following a series of small-vessel ischaemic events. Background of hypertension, dyslipidaemia, and atrial fibrillation on anticoagulation.
**(B-1) Personal Welfare Matters**
In your opinion, does the patient have mental capacity in respect of personal welfare matters?
[ ] Yes
[x] No
[ ] Patient to be referred to a specialist for assessment
If No, in your opinion, is the patient's mental incapacity likely to be permanent?
[x] Yes
[ ] No
[ ] Patient to be referred to a specialist for assessment
**Please state the basis of your opinion above in respect of the patient's mental capacity:**
The patient has an established impairment of the mind, namely moderate to severe vascular dementia secondary to small-vessel cerebrovascular disease. This impairment renders her unable to make decisions regarding personal welfare matters, including consent to medical treatment and decisions about where she lives. On formal assessment with the Mini-Mental State Examination she scored 11 out of 30, with severe impairment of orientation, recall, and judgment. She was unable to understand the nature of decisions put to her regarding her care arrangements, was unable to retain the information for more than a brief period, and was unable to weigh the foreseeable consequences of accepting or declining care. Communication was preserved, with the patient able to express herself verbally in Mandarin. The incapacity is assessed as likely to be permanent in view of the established cerebrovascular pathology and the absence of any reversible contributors.
**(B-2) Property and Affairs Matters**
In your opinion, does the patient have mental capacity in respect of property and affairs matters?
[ ] Yes
[x] No
[ ] Patient to be referred to a specialist for assessment
If No, in your opinion, is the patient's mental incapacity likely to be permanent?
[x] Yes
[ ] No
[ ] Patient to be referred to a specialist for assessment
**Please state the basis of your opinion above in respect of the patient's mental capacity:**
The patient has an established impairment of the mind, namely moderate to severe vascular dementia, which renders her unable to make decisions regarding her financial affairs and property. She was unable to identify her primary sources of income, was unable to state the approximate value of her monthly household expenses, and was unable to understand the implications of a third party transacting on her behalf. Information about her financial circumstances put to her in simple language was not retained, and she was unable to weigh the consequences of decisions regarding her property. All practicable steps to support her decision-making had been taken, including assessment in her preferred language with adequate time and simple visual aids, without success. The incapacity is assessed as likely to be permanent.
**(C) Doctor's Declaration**
I have read and understood the provisions in sections 3, 4 and 5 of the Mental Capacity Act. I believe in the correctness of the opinion set out in this report and I am acting independently of the patient and the patient's next-of-kin.
**Name:** Dr Wong Kah Wai
**MCR No.:** M12847B
**Date:** 03/06/2026
**Signature:**
**Name/Clinic Stamp:**
*\*This medical report is not to be used for deputyship application. The affidavit and medical report to be filed in support of the application for appointment of a deputy or deputies shall be in Form 61.*
*\*\*This medical report alone does not prove that the LPA is valid. This medical report is to be used together with a valid LPA. If you wish to check the validity of any LPA presented to you, please check against the list of Revoked and Suspended LPAs on OPG's website.*
**(A) Patient's Particulars**
**Name (in NRIC):** [patient's full legal name] (Print the patient's full name as registered on their National Registration Identity Card, Foreign Identification Number document, or passport. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**NRIC/FIN/Passport:** [patient's identification number] (Print the patient's National Registration Identity Card number, Foreign Identification Number, or passport number, matching the type of identification provided. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**Date of Birth:** [patient's date of birth] (Print in DD/MM/YYYY format, where DD is the zero-padded day, MM is the zero-padded month, and YYYY is the four-digit year. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**LPA Reference No:** [Lasting Power of Attorney reference number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**(B) Doctor's Opinion on Patient's Mental Capacity**
**Diagnosis:**
[diagnosis pertinent to the mental capacity assessment] (Print only diagnoses pertinent to the mental capacity assessment, such as prior diagnoses of relevant medical conditions including dementia. Confine the content to the assessment. Refrain from stating that the patient has a registered Lasting Power of Attorney or that a donee appointed under a Lasting Power of Attorney should be allowed to transact on the patient's behalf. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**(B-1) Personal Welfare Matters**
In your opinion, does the patient have mental capacity in respect of personal welfare matters? (Mark with '[x]' for the option that applies based on the assessment, and leave '[ ]' for options that do not apply. Only one should be marked.)
[ ] Yes (Mark with '[x]' if the patient is assessed to have mental capacity in respect of personal welfare matters, and leave '[ ]' for information not explicitly mentioned.)
[ ] No (Mark with '[x]' if the patient is assessed to lack mental capacity in respect of personal welfare matters, and leave '[ ]' for information not explicitly mentioned.)
[ ] Patient to be referred to a specialist for assessment (Mark with '[x]' if the patient is to be referred to a specialist for assessment of mental capacity for personal welfare matters, and leave '[ ]' for information not explicitly mentioned.)
If No, in your opinion, is the patient's mental incapacity likely to be permanent? (Mark with '[x]' for the option that applies based on the assessment, and leave '[ ]' for options that do not apply. Only one should be marked. Only complete this question if the question "In your opinion, does the patient have mental capacity in respect of personal welfare matters?" is marked '[x]' for No; otherwise leave all options as '[ ]'.)
[ ] Yes (Mark with '[x]' if the patient's mental incapacity in respect of personal welfare matters is assessed to be likely permanent, and leave '[ ]' for information not explicitly mentioned.)
[ ] No (Mark with '[x]' if the patient's mental incapacity in respect of personal welfare matters is assessed to be not likely permanent, and leave '[ ]' for information not explicitly mentioned.)
[ ] Patient to be referred to a specialist for assessment (Mark with '[x]' if the patient is to be referred to a specialist for assessment of permanence of mental incapacity for personal welfare matters, and leave '[ ]' for information not explicitly mentioned.)
**Please state the basis of your opinion above in respect of the patient's mental capacity:**
[basis of opinion regarding mental capacity for personal welfare matters] (Document the clinical findings underpinning the opinion on mental capacity for personal welfare matters. Personal welfare matters include decisions such as where the patient lives and consent to medical and dental treatment. Apply the two-step test under the Mental Capacity Act. Step 1: document whether the patient has an impairment of, or a disturbance in the functioning of, the mind or brain. Step 2: document whether the impairment makes the patient unable to make the specific decision, with reference to the patient's ability to understand the information relevant to the decision, retain that information, use or weigh that information as part of the process of making the decision, and communicate the decision by talking, sign language, or any other means. Where the mental incapacity is not likely to be permanent, indicate the estimated validity period of this assessment before a newer assessment should be done. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**(B-2) Property and Affairs Matters**
In your opinion, does the patient have mental capacity in respect of property and affairs matters? (Mark with '[x]' for the option that applies based on the assessment, and leave '[ ]' for options that do not apply. Only one should be marked.)
[ ] Yes (Mark with '[x]' if the patient is assessed to have mental capacity in respect of property and affairs matters, and leave '[ ]' for information not explicitly mentioned.)
[ ] No (Mark with '[x]' if the patient is assessed to lack mental capacity in respect of property and affairs matters, and leave '[ ]' for information not explicitly mentioned.)
[ ] Patient to be referred to a specialist for assessment (Mark with '[x]' if the patient is to be referred to a specialist for assessment of mental capacity for property and affairs matters, and leave '[ ]' for information not explicitly mentioned.)
If No, in your opinion, is the patient's mental incapacity likely to be permanent? (Mark with '[x]' for the option that applies based on the assessment, and leave '[ ]' for options that do not apply. Only one should be marked. Only complete this question if the question "In your opinion, does the patient have mental capacity in respect of property and affairs matters?" is marked '[x]' for No; otherwise leave all options as '[ ]'.)
[ ] Yes (Mark with '[x]' if the patient's mental incapacity in respect of property and affairs matters is assessed to be likely permanent, and leave '[ ]' for information not explicitly mentioned.)
[ ] No (Mark with '[x]' if the patient's mental incapacity in respect of property and affairs matters is assessed to be not likely permanent, and leave '[ ]' for information not explicitly mentioned.)
[ ] Patient to be referred to a specialist for assessment (Mark with '[x]' if the patient is to be referred to a specialist for assessment of permanence of mental incapacity for property and affairs matters, and leave '[ ]' for information not explicitly mentioned.)
**Please state the basis of your opinion above in respect of the patient's mental capacity:**
[basis of opinion regarding mental capacity for property and affairs matters] (Document the clinical findings underpinning the opinion on mental capacity for property and affairs matters. Property and affairs matters refer to matters concerning the patient's financial affairs and property. Apply the two-step test under the Mental Capacity Act. Step 1: document whether the patient has an impairment of, or a disturbance in the functioning of, the mind or brain. Step 2: document whether the impairment makes the patient unable to make the specific decision, with reference to the patient's ability to understand the information relevant to the decision, retain that information, use or weigh that information as part of the process of making the decision, and communicate the decision by talking, sign language, or any other means. Where the mental incapacity is not likely to be permanent, indicate the estimated validity period of this assessment before a newer assessment should be done. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**(C) Doctor's Declaration**
"I have read and understood the provisions in sections 3, 4 and 5 of the Mental Capacity Act. I believe in the correctness of the opinion set out in this report and I am acting independently of the patient and the patient's next-of-kin."
**Name:** [doctor's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**MCR No.:** [doctor's Medical Council Registration number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**Date:** [date of report] (Print in DD/MM/YYYY format, where DD is the zero-padded day, MM is the zero-padded month, and YYYY is the four-digit year. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; else omit placeholder, retain section heading and label, and leave blank.)
**Signature:**
**Name/Clinic Stamp:**
_"*This medical report is not to be used for deputyship application. The affidavit and medical report to be filed in support of the application for appointment of a deputy or deputies shall be in Form 61."_
_"**This medical report alone does not prove that the LPA is valid. This medical report is to be used together with a valid LPA. If you wish to check the validity of any LPA presented to you, please check against the list of Revoked and Suspended LPAs on OPG's website."_
(Use third person clinical voice throughout. Apply Singapore English spelling and Ministry conventions, including "judgment" rather than "judgement". Confine the report content to the mental capacity assessment. Refrain from stating that the patient has a registered Lasting Power of Attorney or that a donee appointed under a Lasting Power of Attorney should be allowed to transact on the patient's behalf.)
