IC 16-42-24-7: Use request form

Sec. 7. (a) The state department shall prepare a form for a patient to use to request administration of chymopapain. The form must be substantially in the following form:

REQUEST FOR ADMINISTRATION OF

CHYMOPAPAIN FOR MEDICAL

TREATMENT

Patient's name _______________________________

Address _____________________________________

Age ___________ Sex ____________

Name and address of administering physician

_____________________________________________

Physical condition diagnosed for medical treatment by chymopapain

_____________________________________________

_____________________________________________

My physician has explained the following to me:

(1) That the manufacture and distribution of chymopapain has been banned by the federal Food and Drug Administration.

(2) That there are alternative recognized treatments for the back ailment from which I suffer that my physician has offered to provide for me, including the following: (Here describe)

____________________________________________

____________________________________________

Notwithstanding this explanation, I request the administration of chymopapain in the medical treatment of the back ailment from which I suffer.

_______________________________________

Patient or person signing for patient

ATTEST:

______________________________________

Prescribing physician

(b) A copy of the request form shall be sent immediately after execution to the state department.