|Classification / Identification:|
| ||Form Number:||014-3889-22E||Edition date: ||2018/10 |
| ||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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