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CONSULTING PHYSICIAN COMPLIANCE FORM CONSULTING PHYSICIANS REPORT TERMINAL (Death With Dignity)

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CONSULTING PHYSICIAN COMPLIANCE FORM
A
PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I)
DATE OF BIRTH
B
ATTENDING PHYSICIAN
ATTENDING PHYSICIAN’S NAME (LAST, FIRST, M.I)
TELEPHONE NUMBER
( )
C
CONSULTING PHYSICIAN’S REPORT
TERMINAL DISEASE
DATE OF EXAMINATION(S)
Check boxes for compliance (Both the attending and consulting physicians must make these determinations.)
☐
☐
☐
☐
☐
☐
☐ c
☐
☐
1. Determination that the patient has a terminal disease.
2. Determination that patient has the mental capacity to make medical decisions. **
3. Determination that patient is acting voluntarily.
4. Determination that patient has made his/her decision after being fully informed of:
a) His or her medical diagnosis; and
b) His or her prognosis; and
) The potential risks associated with taking the drug to be prescribed; and
d) The potential result of taking the drug to be prescribed; and
e) The feasible alternatives, including, but not limited to, comfort care, hospice care, palliative care and pain control.
D
PATIENT’S MENTAL STATUS
Check one of the following (required):
☐ I have determined that the individual has the capacity to make medical decisions and is not suffering from impaired
judgment due to a mental disorder.
☐ I have referred the patient to the mental health specialist****listed below for one or more consultations to determine
that the individual has the capacity to make medical decisions and is not suffering from impaired judgment due to a
mental disorder.
☐ If a referral was made to a mental health specialist, the mental health specialist has determined that the patient is not
suffering from impaired judgment due to a mental disorder
MENTAL HEALTH SPECIALIST’S NAME
TELEPHONE NUMBER
( )
DATE
E
CONSULTANT’S INFORMATION
PHYSICAN’S SIGNATURE
DATE
NAME (PLEASE PRINT)
MAILING ADDRESS
CITY, STATE, AND ZIP CODE
TELEPHONE NUMBER
( )
**Capacity to make medical decisions means that, in the opinion of an individual’s attending physician, consulting physician, psychiatrist, or
psychologist, pursuant to Section 4609 of the Probate Code, the individual has the ability to understand the nature and consequences of a
health care decision, the ability to understand its significant benefits, risks, and alternatives, and the ability to make
**** Mental Health Specialist means a psychiatrist or a licensed psychologist.
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CONSULTING PHYSICIAN COMPLIANCE FORM CONSULTING PHYSICIANS REPORT TERMINAL (Death With Dignity)

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Completed 11 March 2021

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