2015 Kentucky Revised Statutes
CHAPTER 311 - PHYSICIANS, OSTEOPATHS, PODIATRISTS, AND RELATED MEDICAL PRACTITIONERS
311.958 Written informed request.

KY Rev Stat § 311.958 (2015) What's This?

Download as PDF 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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