Find a Provider | Academy of Aid-in-Dying Medicine

*Patient Name*

First Last

*Date of birth*

*Age*

Gender*

Male, female, trans‑male, trans‑female, non‑binary, or prefer not to say

This field is hidden when viewing the form

Gender

Female
Male
Transgender male
Transgender female
Nonbinary (gender neutral)
prefer not to say

*Patient's address*

Street Address City State / Province / Region ZIP / Postal Code

Direct PHONE for patient or designated contact (not hospice/staff)*

Direct EMAIL for patient or designated contact (not hospice/staff)*

SECONDARY EMAIL for patient or designated contact (not hospice/staff)*

List up to 4 contacts (names, phone, and email) we may communicate with (besides the patient)

name (and relationship to patient)	phone number	email

Has the patient or their authorized representative read the “Essential Patient Information” page? If not, please review it using the tab above.*

Yes

Diagnosed life‑limiting or terminal illness (please specify; do not include unrelated or non‑terminal conditions such as mental health conditions or dementia)*

If aid‑in‑dying is not legal where the patient lives, would they consider relocating to a state where it is (e.g., Washington, Oregon, California, Colorado, Hawaii, New Jersey, New Mexico) to receive this care?

Is the patient enrolled in a hospice?*

Yes
No
planning this soon

Which hospice is the patient enrolled in, and when did care with that hospice begin?

Has the patient ever been evaluated for medical aid in dying? If yes, please provide the provider’s name, date, and outcome of the evaluation.

Mobility: Is the patient able to attend an office visit?*

Is the patient able to swallow 2–4 ounces of liquid comfortably within two minutes? (This is not required for aid in dying but helps us plan an appropriate referral)*

Yes
No, but the patients has a feeding tube.
The patient will require a provider who can support with non-oral options for taking the medications.

Which healthcare system or organizations have provided the patient's care in the last year? (not the insurance you use)*

Are any of the patient's current providers willing and authorized to serve as the attending/prescribing provider for medical aid in dying? (Note that "supporting" aid in dying does not indicate they are willing or authorized)*

Are any of the patient's current providers willing and authorized to serve as the consulting/2nd option provider for medical aid in dying?*

What are the patient’s thoughts on the possible timing for taking the aid‑in‑dying medications—days, weeks, or months away—or is the timing unknown?*

Any special communication needs?

If the patient lives in a facility, have administrators been asked about proceeding with aid‑in‑dying on the premises?

Fees, speed of care, and bedside service vary by provider (independent provider, healthcare system, hospice). Please indicate any preferences or significant financial constraints.

How did you learn about this referral system?*

*Please review the following statements carefully as you are being asked to release certain claims against the Academy of Aid-in-Dying Medicine in order to access this service.*

I have read and agree to the Academy of Aid-in-Dying Medicine’s Referral Policy as noted below

By selecting “I have read and agree to the Academy of Aid-in-Dying Medicine’s (the Academy) Referral Policy”, you acknowledge, understand, and agree to the following:
1) The Academy is not engaged in the practice of medicine or any other profession and no patient-physician relationship is formed between me and the Academy through my use of this referral system;
2) The Academy operates this referral system as a public service and its role in facilitating this referral system is limited to connecting patients with potential physicians;
3) The Academy confirms that the physicians who participate in the referral system are licensed with a state Medical Board, but AADM has not and does not perform any additional quality checks and does not otherwise vet the physicians who participate in this referral system;
4) The Academy is not responsible for the care that the physicians in the referral system provide and does not attest to the quality of care these physicians may provide;
5) The Academy expressly disclaims any and all warranties in connection with the operation of this referral system; and
6) I HEREBY RELEASE THE ACADEMY, ITS REFERRAL SYSTEM, AND ANY OF THEIR OFFICERS, EMPLOYEES, AND COMMITTEE MEMBERS FROM ANY LIABILITY, LOSSES, DAMAGES, CLAIMS, CAUSES OF ACTION, INTEREST, EXPENSES, COSTS, AND ATTORNEYS’ FEES ARISING OUT OF OR RELATED TO THE REFERRAL.
7) If you do not agree to these terms, you may not access the referral system.

Find Aid-in-Dying Care

Please read our
Essential Information
for Patients and Families

Patient Intake Form

Teaching and supporting best practices for the care of patients considering or completing medical aid in dying.

Find Aid-in-Dying Care

Please read our Essential Information for Patients and Families

Patient Intake Form

Teaching and supporting best practices for the care of patients considering or completing medical aid in dying.

Please read our
Essential Information
for Patients and Families