Fillable PSYCHIATRIC/PSYCHOLOGICAL CONSULTANTS COMPLIANCE FORM PLEASE PRINT A PATIENT (Death With Dignity)

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PSYCHIATRIC/PSYCHOLOGICAL CONSULTANTS COMPLIANCE FORM PLEASE PRINT A PATIENT (Death With Dignity)

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PLEASE PRINT
PSYCHIATRIC/PSYCHOLOGICAL CONSULTANT’S COMPLIANCE FORM
ORS 127.800 - ORS 127.897
Deliver this form to the attending/prescribing physician who will mail it to:
Oregon State Public Health Division, Center for Health Statistics,
P.O. Box 14050, Portland, OR 97293-0050
PLEASE PRINT
A PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I.): DATE OF BIRTH:
B REFERRING/PRESCRIBINGPHYSICIAN
REFERRING PHYSICIAN’S NAME (LAST, FIRST, M.I.): TELEPHONE NUMBER:
C PSYCHIATRIC / PSYCHOLOGICAL EVALUATION
1. MEDICAL DIAGNOSIS
DATE(S) OF EXAMINATION(S):
2. PSYCHIATRIC
/
PSYCHOLOGICAL EVALUATION
D PSYCHIATRIC/PS
Y
CHOLOGICALCONSULTANT’SINFORMATION
I have determined through evaluation that the above-named patient is not suffering from a psychiatric or psychological
disorder, or depression causing impaired judgment, in conformance with ORS 127.825.
CONSULTANT’S SIGNATURE AND TITLE (e.g., M.D., Ph.D., etc.):
CONSULTANT’S NAME (PRINTED): DATE:
MAILING ADDRESS:
CITY, STATE AND ZIP CODE: TELEPHONE NUMBER:
Copies of this form are available at: http://www.healthoregon.org/dwd Rev. 5/18
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PSYCHIATRICPSYCHOLOGICAL CONSULTANTS COMPLIANCE FORM PLEASE PRINT A PATIENT (Death With Dignity)

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Completed 11 March 2021

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