Kansas Statutes Chapter 65. Public Health § 65-6b05. Same; written informed request

The “written informed request” referred to in this act shall be on a form prepared by, and obtained from the state board of healing arts and shall be in substance as follows:

WRITTEN INFORMED REQUEST FOR PRESCRIPTION OF AMYGDALIN (LAETRILE) FOR MEDICAL TREATMENT

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 its use as a dietary supplement:

____________________________________________________________

____________________________________________________________

My physician has explained to me:

____________________________________________________________

____________________________________________________________

That notwithstanding the foregoing, I hereby request prescription and use of amygdalin (laetrile) (a) in the medical treatment of the malignancy, disease, illness or physical condition from which I suffer ☐, (b) as a dietary supplement ☐ or (c) both in the medical treatment of the malignancy, disease, illness or physical condition from which I suffer and as a dietary supplement ☐ (check (a), (b) or (c)).

________________________________________

Patient or person signing for patient

ATTEST:

________________________________________

Prescribing Physician

A copy of such written informed request shall be forwarded forthwith after execution thereof to the medical care facility or other health care facility and the state board of healing arts.