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.

Cardiologist's Name*

Cardiologist's Phone*

Affiliated Hospital*

Parent/Legal Guardian Information:

Parent/Legal Guardian #1 First Name*

Parent/Legal Guardian #1 Last Name*

Parent/Legal Guardian #1 Phone*

Parent/Legal Guardian #1 mobile

Parent/Legal Guardian #1 Email*

Parent/Legal Guardian #1 Address

Street*

Submit