Information from this Participating Physician form will be used only to send you intake information about patients in your geographic area who are seeking a physician to evaluate their aid-in-dying request. These patients (who contact us via our intake form) are screened by the Academy before sending you their information. No patient will ever be given your information, and your participation in this list will be strictly confidential.

NOTE: The Academy Hotline is available for advice free of charge if you have any questions or needs in caring for referred patients.

Contact us for questions or information: [email protected]