Evolution of Euthanasia by Jessica French: Physician and Patient Materials

The following forms are distributed by each states' Department of Health.  These forms are used to ensure that physicians are in compliance with the Death with Dignity Act implemented individually by Oregon, Vermont, and Washington.  

Required Forms: Purstant to Or. Stat. §§ 127.800-127.995

• Patient Request Form​

• Attending Physician Form

• Attending Physician Short Form

• Consulting Physician Form

• Psychiatrist/Psychologist Form

• Pharmacy Dispensing Record Form 

• Attending Physician Follow-Up Form

• Chronology and Death Certificate Extract Form

"The following forms are provided by the Department of Health to assist patients and physicians in undertaking the mandatory reporting requirements. The use of these forms is not mandatory."

Physician Reporting Form

Consulting Physician Reporting Form

Patient Request for Medication Form

Patient Forms

• Written Request for Medication to End My Life in a Humane and Dignified Manner form, DOH 422-063 (PDF)

Provider Forms

• Attending Physician's Compliance form, DOH 422-064 (PDF)

• Consulting Physician's Compliance form, DOH 422-065 (PDF)

• Psychiatric/Psychological Consultant's Compliance form, DOH 422-066 (PDF) 

• Pharmacy Dispensing Record form, DOH 422-067 (PDF)

• Attending Physician's After Death Reporting form, DOH 422-068 (PDF)