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311.958 Written informed request.
"Written informed request" is a form which shall be prepared and distributed by the
State Board of Medical Licensure and shall be in substance as follows:
WRITTEN INFORMED REQUEST FOR PRESCRIPTION OF AMYGDALIN
(Laetrile) FOR MEDICAL TREATMENT AND RELEASE OF PHYSICIAN FROM
LIABILITY
Patient's
Name...................................................................................................................
Address.........................................................................................................................
....
Age...............................Sex...........................................................................................
....
Name and Address of prescribing physician:
......................................................................................................................................
....
......................................................................................................................................
....
Malignancy, disease, illness or physical condition diagnosed for medical treatment
by amygdalin (laetrile):
......................................................................................................................................
....
......................................................................................................................................
....
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) 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
malignancy, disease, illness, or physical condition from which I suffer which he has
offered
to
provide
for
me
including:
(here
describe)........................................................................................................................
.
That notwithstanding the foregoing, I hereby request prescription and use of
amygdalin (laetrile) in the medical treatment of the malignancy, disease, illness, or
physical condition from which I suffer.
I hereby release the physician from any and all liability due to any deleterious
consequences that may be directly attributable to the use of amygdalin (laetrile).
..........................................................
Patient or person signing for
patient
ATTEST:
........................................................................
Prescribing physician
Effective:July 15, 1980
History: Created 1980 Ky. Acts ch. 354, sec. 5, effective July 15, 1980.
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