|Classification / Identification:|
| ||Form Number:||014-3890-22E||Edition date: ||2019/06 |
| ||Title:||Clinician Aid B - (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid|
| ||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 maintaining records of requests for medical assistance in dying. Please use this aid if you are a “Medical Practitioner” or “Nurse Practitioner” and a patient is requesting medical assistance in dying and it is your intention to provide medical assistance in dying to the patient. You should also include the completed aid in the patient's medical records.|| || |
You must download Adobe Acrobat Reader (version 10.0 or above) to view/print PDF forms.
Click here for further instructions.
If PDF forms do not open in the latest versions of Firefox and Chrome, click here for the solution.
Protecting Your Information:
If you are using this online service on a shared computer in a public area (i.e. public library), it is important to ensure that you do not leave the computer unattended while accessing the service. Before leaving the computer, it is also important that you fully exit the application, clear your browser's cache (This link opens in a new window)
and close down your browser. This will ensure that no one else can access any personal information you may have entered.