Indiana Code Title 16. Health § 16-42-23-5

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:

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))

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.