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Form Format
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Adobe PDF   Clinician Aid A - Patient Request for Medical Assistance In DyingThe file you are about to download will ONLY work properly if opened with an Adobe Reader 10 or later client. Please do not open this file in a browser.Fill, Print & Save1113.0 kb

Form Classification
Classification / Identification:
 Form Number:014-3889-22EEdition date: 2019/06 
 Title:Clinician Aid A - Patient Request for Medical Assistance in Dying
 Ministry:Health and Long-Term Care  
 Branch/ABC:Strategic Policy Branch  
 Program:Strategic Policy – Medical Assistance in Dying  
 Purpose of Form:The use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements. Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.  

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