311.958 Written informed request.
"Written informed request" is a form which shall be prepared and distributed by the State <br>Board of Medical Licensure and shall be in substance as follows: <br>WRITTEN INFORMED REQUEST FOR PRESCRIPTION OF AMYGDALIN (Laetrile)
FOR MEDICAL TREATMENT AND RELEASE OF PHYSICIAN FROM LIABILITY
Patient's Name................................................................................................................... <br>Address............................................................................................................................. <br>Age...............................Sex............................................................................................... <br>Name and Address of prescribing physician: <br>.......................................................................................................................................... <br>.......................................................................................................................................... <br>Malignancy, disease, illness or physical condition diagnosed for medical treatment by <br>amygdalin (laetrile): <br>.......................................................................................................................................... <br>.......................................................................................................................................... <br>My physician has explained to me:
(a) That the manufacture and distribution of amygdalin (laetrile) has been banned
by the Federal Food and Drug Administration.
(b) That neither the American Cancer Society, the American Medical Association,
nor the Kentucky Medical Association recommend use of amygdalin (laetrile) <br>in the treatment of any malignancy, disease, illness, or physical condition.
(c) That I am terminally ill and there are alternative recognized treatments for the <br>malignancy, disease, illness, or physical condition from which I suffer which he has <br>offered
to
provide
for
me
including:
(here
describe)......................................................................................................................... <br>That notwithstanding the foregoing, I hereby request prescription and use of amygdalin <br>(laetrile) in the medical treatment of the malignancy, disease, illness, or physical <br>condition from which I suffer. <br>I hereby release the physician from any and all liability due to any deleterious <br>consequences that may be directly attributable to the use of amygdalin (laetrile). <br>
...........................................................
Patient or person signing for patient
ATTEST: <br>........................................................................ <br>Prescribing physician
Effective: July 15, 1980 <br>History: Created 1980 Ky. Acts ch. 354, sec. 5, effective July 15, 1980.
Disclaimer: These codes may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
