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Patient Choice At End Of Life Form - Physician Follow-Up - Vermont Department Of Health

Patient Choice at End of Life — Physician Follow-up

Mail form to:

Vermont Department of Health, Vital Records

P.O. Box 70, Burlington, VT 05402-0070

Dear Physician:

The Rule Governing Compliance with Patient Choice At End Of Life requires physicians

who write a prescription for a lethal dose of medication to complete this follow-up form

within 10 calendar days of a patient's death, if known to the physician, or 60 calendar

days from the writing of the prescription.

For the Department of Health to accept this form, it must be signed by the Prescribing

Physician, whether or not he or she was present at the patient’s time of death.

This form should be mailed to the address above. All information is kept strictly

confidential. If you have any questions, call: 802-651-1862.

Patient’s Name: ______________________________________ DOB: ____/____/____

Name of Prescribing Physician: ______________________________________________

Did the patient die from ingesting the lethal dose of medication, from their underlying

illness, or from another cause such as terminal sedation or ceasing to eat or drink? If

unknown, please mark the form indicating that.

1. Patient Choice (lethal medication)

2. Underlying illness

3. Unknown

4. Other (please specify):

____________________________________________________________

Prescribing Physician Signature: _____________________________________________

Date: ____/____/____

Patient Choice At End Of Life Form - Physician Follow-Up - Vermont Department Of Health