Indiana Code Title 16. Health § 16-42-24-7

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:

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:

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.