AB552,11,15 I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care, and pain control.

AB552,11,17 I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.

AB552,11,18 INITIAL ONE OF THE FOLLOWING 3 STATEMENTS:

AB552,11,20 .... I have informed my family members of my decision and taken their opinions into consideration.

AB552,11,21 .... I have decided not to inform my family of my decision.

AB552,11,22 .... I have no family to inform of my decision.

AB552,11,23 I understand that I have the right to revoke this request at any time.

AB552,11,25 I understand the full import of this request and I expect to die when I take the medication to be prescribed.

AB552,12,2 I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.

AB552,12,3 Signed: ....

AB552,12,4 Dated: ....

AB552,12,5 Statement and signatures

AB552,12,6 of witnesses

AB552,12,16 I know the requester personally or I have received proof of his or her identity and I believe him or her to be of sound mind and at least 18 years of age. I believe that the requester makes this request voluntarily. I am at least 18 years of age, am not related to the requester by blood, marriage, or adoption, and am not directly financially responsible for the requester's health care. I am not a health care provider who is serving the requester at this time; an employee of the health care provider, other than a chaplain or a social worker; or an employee, other than a chaplain or a social worker, of a health care facility in which the requester is a patient. To the best of my knowledge, I am not entitled to and do not have a claim on the requester's estate.

AB552,12,17 Witness No. 1:

AB552,12,18 (print) Name: ....

AB552,12,19 Address: ....

AB552,12,20 Signature: ....

AB552,12,21 Witness No. 2:

AB552,12,22 (print) Name: ....

AB552,12,23 Address: ....

AB552,12,24 Signature: ....

AB552,12,25 Witness No. 3:

AB552,13,1 (print) Name: ....

AB552,13,2 Address: ....

AB552,13,3 Signature: ....

AB552,13,7 If the requester is a resident of a nursing home or community-based residential facility, at least one of the above witnesses must be a residents' advocate designated by the board on aging and long-term care. A residents' advocate who is a witness should print “residents' advocate" after the printing of his or her name above.

AB552,13,9 156.17 Revocation of request for medication. (1) A requester may revoke his or her request for medication at any time by doing any of the following:

AB552,13,12 (a) Canceling, defacing, obliterating, burning, tearing, or otherwise destroying the written request for medication or directing another in the presence of the requester to destroy, in the same manner, the request for medication.