Santa Fe Mobile MD - Secure Request Form v3

Request for Medication to End My Life in a Peaceful Manner

iPad entry form. The final PDF is generated from a separate compact state-form-style template.

1. Patient / Requesting Person

Each acknowledgment statement below must be initialed separately.

I am an adult of sound mind. I am suffering from a terminal illness, which is a disease or condition that is incurable and irreversible that, according to reasonable medical judgment, will result in my death within six months. My health care provider has determined that the illness is in its terminal phase.

Not initialed
Required
I have been fully informed of my diagnosis and prognosis, the nature of the medical aid in dying medication to be prescribed and the potential associated risks, the expected result and the feasible alternative, concurrent or additional treatment opportunities, including hospice care and palliative care focused on relieving symptoms and reducing suffering.
Not initialed
Required
I request that my health care provider prescribe medication that will end my life in a peaceful manner, if I choose to self-administer the medication, and I authorize my health care provider to contact a willing pharmacist to fulfill this request.
Not initialed
Required
I understand that I have the right to rescind this request at any time.
Not initialed
Required
I understand the full import of this request, and I expect to die if I self-administer the medical aid in dying medication prescribed. I further understand that although most deaths occur within three hours, my death may take longer. My health care provider has counseled me about this possibility.
Not initialed
Required
I make this request voluntarily and without reservation.
Finger or Apple Pencil

2. Declaration of Witnesses

We declare that the person signing this request:

  1. is personally known to us or has provided proof of identity;
  2. signed this request in our presence;
  3. appears to be of sound mind and not under duress, fraud or undue influence; and
  4. is not a patient for whom either of us is a health care provider.

3. Witness 1

4. Witness 2

5. Provider

6. Review & Finalize

Prototype data is not transmitted.
SANTA FE MOBILE MD
Where expert care comes to you!
www.santafemobilemd.com
1640 Calle Medico Ste E Santa Fe NM 87505 | Main 505-386-1380 | Fax 505-393-3883
doctor@santafemobilemd.com
REQUEST FOR MEDICATION TO END MY LIFE IN A PEACEFUL MANNER
I, , am an adult of sound mind. I am suffering from a terminal illness, which is a disease or condition that is incurable and irreversible that, according to reasonable medical judgment, will result in my death within six months. My health care provider has determined that the illness is in its terminal phase.
(Patient Initials)
I have been fully informed of my diagnosis and prognosis, the nature of the medical aid in dying medication to be prescribed and the potential associated risks, the expected result and the feasible alternative, concurrent or additional treatment opportunities, including hospice care and palliative care focused on relieving symptoms and reducing suffering.
(Patient Initials)
I request that my health care provider prescribe medication that will end my life in a peaceful manner, if I choose to self-administer the medication, and I authorize my health care provider to contact a willing pharmacist to fulfill this request.
(Patient Initials)
I understand that I have the right to rescind this request at any time.
(Patient Initials)
I understand the full import of this request, and I expect to die if I self-administer the medical aid in dying medication prescribed. I further understand that although most deaths occur within three hours, my death may take longer. My health care provider has counseled me about this possibility.
(Patient Initials)
I make this request voluntarily and without reservation.
Signed:
Date:
Time:
DECLARATION OF WITNESSES:
We declare that the person signing this request:
  1. is personally known to us or has provided proof of identity.
  2. signed this request in our presence.
  3. appears to be of sound mind and not under duress, fraud or undue influence; and
  4. is not a patient for whom either of us is a health care provider.

Witness 1

Signature
Printed Name
Relationship to Patient
Date

Witness 2

Signature
Printed Name
Relationship to Patient
Date
Provider Printed Name:
Provider Signature:
Date:
NOTE: No more than one witness shall be a relative by blood, marriage or adoption of the person signing this request. No more than one witness shall own, operate or be employed at a healthcare facility where the person signing this request is a patient or resident.