A prescribing health care provider may provide a prescription for medical aid in dying medication to an individual only after the prescribing health care provider has:
"REQUEST FOR MEDICATION TO END MY LIFE IN A PEACEFUL MANNER
I, ______________________________________________, am an adult of sound mind.
I am suffering from a terminal illness, which is a disease or condition that is incurable and irreversible and that, according to reasonable medical judgment, will result in my death within six months. My health care provider has determined that the illness is in its terminal phase. _____ (Patient Initials)
I have been fully informed of my diagnosis and prognosis, the nature of the medical aid in dying medication to be prescribed and the potential associated risks, the expected result and the feasible alternative, concurrent or additional treatment opportunities, including hospice care and palliative care focused on relieving symptoms and reducing suffering. _____ (Patient Initials)
I request that my health care provider prescribe medication that will end my life in a peaceful manner if I choose to self-administer the medication, and I authorize my health care provider to contact a willing pharmacist to fulfill this request. _____ (Patient Initials)
I understand that I have the right to rescind this request at any time. _____ (Patient Initials)
I understand the full import of this request, and I expect to die if I self-administer the medical aid in dying medication prescribed. I further understand that although most deaths occur within three hours, my death may take longer. My health care provider has counseled me about this possibility. _____ (Patient Initials)
I make this request voluntarily and without reservation.
Signed: ___________________________________________
Date: ____________________
Time: ___________________
DECLARATION OF WITNESSES:
We declare that the person signing this request:
Witness 1: Witness 2:
Signature: __________________ _________________
Printed Name: __________________ _________________
Relationship to Patient: __________________ _________________
Date: __________________ _________________.
NOTE: No more than one witness shall be a relative by blood, marriage or adoption of the person signing this request. No more than one witness shall own, operate or be employed at a health care facility where the person signing this request is a patient or resident.".
NMS § 24-7C-3