IC 16-42-23-5: Written informed request form

Sec. 5. (a) The written informed request must be on a form prepared by and obtained from the medical licensing board of Indiana and must be in substance as follows:

WRITTEN INFORMED REQUEST

FOR PRESCRIPTION OF AMYGDALIN

(LAETRILE) FOR MEDICAL

TREATMENT

| 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) or the use of amygdalin as a dietary supplement:

| ________________________________________

| ________________________________________

My physician has explained the following to me:

(1) That the manufacture and distribution of amygdalin (laetrile) has been banned by the Federal Food and Drug Administration.

(2) That neither the American Cancer Society, the American Medical Association, nor the Indiana State Medical Association recommend use of amygdalin (laetrile) in the treatment of a malignancy, a disease, an illness, or a physical condition.

(3) That there are alternative recognized treatments for the malignancy, disease, illness, or physical condition from which I suffer that my physician has offered to provide for me, including the following:

(Here describe)

______________________________________

______________________________________

Notwithstanding this explanation, I request prescription and use of amygdalin (laetrile):

(1) in the medical treatment of the malignancy, disease, illness, or physical condition from which I suffer ( ); or

(2) as a dietary supplement ( ).

(Check (1) or (2))

________________________________________

Patient or person signing for patient

ATTEST:

__________________________________

Prescribing physician

(b) A copy of the written informed request shall be forwarded after execution to the medical licensing board of Indiana for appropriate filing.