Form of written request

(1) A request for medical aid-in-dying medication authorized by this article 48 must be in substantially the following form: Request for medication to end my life in a peaceful manner I, _______________ am an adult of sound mind. I am suffering from _______________, which my attending provider has determined is a terminal illness and which has been medically confirmed. I have been fully informed of my diagnosis and prognosis of six months or less, the nature of the medical aid-in-dying medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment opportunities, including comfort care, palliative care, hospice care, and pain control. I request that my attending provider prescribe medical aid-in-dying medication that will end my life in a peaceful manner if I choose to take it, and I authorize my attending provider to contact any pharmacist about my request. I understand that I have the right to rescind this request at any time. I further understand that although most deaths occur within three hours, my death may take longer, and my attending provider has counseled me about this possibility. I make this request voluntarily, without reservation, and without being coerced, and I accept full responsibility for my actions. Signed: _______________ Dated: ________________ Declaration of witnesses We declare that the individual signing this request: Is personally known to us or has provided proof of identity; Signed this request in our presence; Appears to be of sound mind and not under duress, coercion, or undue influence; and I am not the attending provider for the individual. _______________ witness 1/date _______________ witness 2/date Note: Of the two witnesses to the written request, at least one must not: Be a relative (by blood, marriage, civil union, or adoption) of the individual signing this request; be entitled to any portion of the individual's estate upon death; or own, operate, or be employed at a health-care facility where the individual is a patient or resident. And neither the individual's attending or consulting provider nor a person authorized as the individual's qualified power of attorney or durable medical power of attorney shall serve as a witness to the written request.