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Mikey’s Kids Application – Physician or Parent

Physicians or parents of a child in need of a MIKEY, can apply using the form below. If you are an organization looking to place a MIKEY at your location, please use the application here.

The Mikey Network is a registered Canadian charity, governed by rules and regulations set forth by the Canada Revenue Agency. Our charter limits us to only consider requests for a MIKEY defibrillator from residents of Canada.

Fields with (*) are required

Applicant's Name (person making this application)*:  

Applicant's Email:  


Cardiac Physician's Name*:  

Physician Email:  

Physician Phone*: 

Referring Hospital (If applicable):  


Parent/Legal Guardian #1 Name*: 

Parent/Legal Guardian #1 Address*: 

City*:

Province*:

Postal Code*:

Parent/Legal Guardian #1 Home Phone*: 

Parent/Legal Guardian #1 Cell Phone: 

Parent/Legal Guardian #1 Work Phone: 

Parent/Legal Guardian #1Email*: 

Parent/Legal Gaurdian #2 Name: 

Parent/Legal Guardian #2 Email: 


Child's Name*: 

Child's Date of Birth*: 

Child's Diagnosis*: 


Additional Information:

I authorize The Mikey Network to contact the Physician named in this application to discuss personal medical information as it relates to this application.*

 

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