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HUMANE AND DIGNIFIED MANNER
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I, .... (insert name), am an adult of sound mind, do not have incapacity, and am
9a resident of Wisconsin.
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I am suffering from .... (insert description of terminal disease), which my
11attending physician has determined is a terminal disease and which has been
12medically confirmed by a consulting physician.
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I have been fully informed of my diagnosis, prognosis, the nature of medication
14to be prescribed and potential associated risks, the expected result, and the feasible
15alternatives, including comfort care, hospice care, and pain control.
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I request that my attending physician prescribe medication that will end my life
17in a humane and dignified manner.
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INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:
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.... I have informed my family members of my decision and taken their opinions
20into consideration.
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.... I have decided not to inform my family of my decision.
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.... I have no family to inform of my decision.
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I understand that I have the right to revoke this request at any time.
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I understand the full import of this request and I expect to die when I take the
25medication to be prescribed.
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1I make this request voluntarily and without reservation, and I accept full moral
2responsibility for my actions.
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I know the requester personally or I have received proof of his or her identity
8and I believe him or her to be of sound mind and at least 18 years of age. I believe
9that the requester makes this request voluntarily. I am at least 18 years of age, am
10not related to the requester by blood, marriage, or adoption, and am not directly
11financially responsible for the requester's health care. I am not a health care
12provider who is serving the requester at this time; an employee of the health care
13provider, other than a chaplain or a social worker; or an employee, other than a
14chaplain or a social worker, of a health care facility in which the requester is a
15patient. To the best of my knowledge, I am not entitled to and do not have a claim
16on the requester's estate.