Among the provisions of the Elizabeth Whitefield End of Life Options Act is a requirement that the individual requesting the aid-in-dying medication complete a “Request for Medication to End My Life In a Peaceful Manner” form (see below). By law, this form must be entered into the individual’s medical health record after the form has been completed with all of the required signatures and initials.
To download the “Request for Medication to End My Life In a Peaceful Manner” form, click here.