New Jersey Statutes Title 24. Food and Drugs 24 § 6F-1

No duly licensed physician shall be subject to any penalty or disciplinary action by any State agency or private professional organization solely for prescribing, administering or dispensing amygdalin, also known as laetrile or vitamin B-17, to a patient who has made a written request for such substance on the following form:

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)

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 ☐, or (b) as a dietary supplement ☐. Check (a) or (b).

Attest: