§ 16-42-24-7 — Use request form

Indiana § 16-42-24-7

• Jurisdiction: Indiana
• Title 16: HEALTH
• Art. 42: REGULATION OF FOOD, DRUGS, AND
• Ch. 24: Drugs: Use of Chymopapain

Text

(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:
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.
ATTEST:
______________________________________
Prescribing physician
(b) A copy of the request form shall be sent immediately after
execution to the state department.
[Pre-1993 Recodification Citation: 16-8-10-5.]

Legislative History

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