Form of final attestation

(a) A final attestation form shall be given to a qualified patient at the time an attending provider writes or dispenses the prescription authorized by this chapter and shall be in substantially the following form: "FINAL ATTESTATION FOR A REQUEST FOR MEDICATION TO END MY LIFE I, ______________________, am an adult of sound mind. I am suffering from ___________, which my attending provider has determined is a terminal disease and that has been medically confirmed by a consulting provider. I have received counseling to determine that I am capable and not suffering from undertreatment or nontreatment of depression or other conditions which may interfere with my ability to make an informed decision. I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, the possibility that I may choose not to obtain or not to use the medication, and the feasible alternatives or additional treatment options, including comfort care, hospice care, and pain control. I understand that I am requesting that my attending provider prescribe medication that I may self-administer to end my life. INITIAL ONE: _______ I have informed my family of my decision and taken their opinions into consideration. _______ I have decided not to inform my family of my decision. _______ I have no family to inform of my decision. I understand that I have the right to rescind this request at any time. I understand that I still may choose not to use the medication prescribed and by signing this form I am under no obligation to use the medication prescribed. I am fully aware that the prescribed medication will end my life and while I expect to die when I take the medication prescribed, I also understand that my death may not be immediate and my attending provider has counseled me about this possibility. I make this request voluntarily and without reservation. Signed: ____________________ Dated: ____________________" (b) The final attestation form shall be completed by the qualified patient within forty-eight hours prior to the qualified [patient's] self-administration of the medication prescribed pursuant to this chapter. Upon the qualified patient's death, the completed final attestation form shall be delivered by the qualified patient's health care provider, family member, or other representative to the attending provider for inclusion in the qualified patient's medical record.