§ 16-42-23-5 — Written informed request form

(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:
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))
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.
[Pre-1993 Recodification Citation: 16-8-8-5.]

Legislative History

As added by P.L.2-1993, SEC.25.