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am an adult of sound mind and a (Death With Dignity)

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FINAL ATTESTATION FOR AN AID-IN-DYING DRUG TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
I, __________________________________________________________________________________,
am an adult of sound mind and a resident of the State of California.
I am suffering from ___________________________________________________________________,
which my attending physician has determined is in its terminal phase and which has been medically
confirmed.
I have been fully informed of my diagnosis and prognosis, the nature of the aid-in-dying drug to be
prescribed and potential associated risks, the expected result, and the feasible alternatives or additional
treatment options, including comfort care, hospice care, palliative care, and pain control.
I have received the aid-in-dying drug and am fully aware that this aid-in-dying drug will end my life in a
humane and dignified manner.
INITIAL ONE:
_____
I have informed one or more members of my family of my decision and taken their opinions
into consideration.
_____
I have decided not to inform my family of my decision.
_____
I have no family to inform of my decision.
My attending physician has counseled me about the possibility that my death may not be immediately
upon the consumption of the drug.
I make this decision to ingest the aid-in-dying drug to end my life in a humane and dignified manner. I
understand I still may choose not to ingest the drug and by signing this form I am under no obligation to
ingest the drug. I understand I may rescind this request at any time.
Signed:__________________________________________________________
Dated:__________________________________________________________
Time:___________________________________________________________
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am an adult of sound mind and a (Death With Dignity)

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Completed 11 March 2021

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