Patient Intake Form – American Clinicians Academy on Medical Aid in Dying

The American Clinicians Academy on Medical Aid in Dying Patient-to-Doctor Referral System:

If you have a terminal condition and are considering aid in dying, we will refer you to physicians who can consider your aid-in-dying request. The requirements are that you:
Live in a state where aid in dying is legal
Have a terminal diagnosis with a less than six-month prognosis
*Have the capacity to make your own medical decisions.

Please be sure to ask your present doctors about your request. If they are not experienced with aid in dying, let them know that the Academy’s physicians will work with them on the details, from the law to the medications used. There is no charge for this and they do not have to be a member of the Academy. Please share our contact information with your doctors: [email protected]

If you have approached your doctors about medical aid in dying and continue to need a referral to a physician who will participate, please fill out our referral intake form below.

Here are some details about Completing the Path to Medical Aid in Dying.

Here is an explanation of the Potential Fees and Expenses for Medical Aid in Dying. Please read this.

Submitting this form is your permission for us to share your information with potential aid-in-dying physicians and other related health care providers who may participate in your evaluation for and/or care related to medical aid in dying.

NOTE: Please pay attention to the details of the questions below, and answer completely. Partial information will lead to a delay in the referral.

If you complete this form and enter “Submit” and are not taken to the confirmation page, you have left required fields blank and we will not receive your form. Please fill in the missing fields and then Submit the form.

Patient Name*
First Last
Date of birth*
Age*
Gender
- Female
- Male
- Transgender male
- Transgender female
- Nonbinary (gender neutral)
Terminal Illness (be specific, not just "cancer," etc.*
Patient's address*
Street Address City State / Province / Region ZIP / Postal Code
Phone # to reach patient*
Best email to reach patient?*
Person filling out this form, if not the patient
First Last
If not the patient, please let us know your relationship to the patient
Best email to reach person filling out this form
Best phone number to reach person filling out this form
Other contact for the patient
First Last
Other contact's relationship to the patient.
Other Contact's Phone Number
Other Contact's email
Are you enrolled in a hospice?*
Which hospice are you enrolled in, and when did you begin care with that hospice?
Mobility: Can you go to an office visit?*
Are you able to swallow 4 ounces of liquid in two minutes? (This is not required for aid in dying, but is helpful in our planning an appropriate referral.)
- Yes
- No
- No, but I have a feeding tube.
- No, but I would like to talk about other options for taking the medications.
PLEASE READ THIS FULLY AND REPLY TO ALL ASPECTS. Which doctors and health care organizations have provided care in the last year? Include all doctors, not only those caring for the terminal disease. Please be specific, doctors' names (FIRST AND LAST), specialty, rough timing of your last visits, NAME OF HEALTH CARE SYSTEM THEY WORK WITH, IF APPLICABLE (DO NOT LEAVE THIS OUT, IT IS ESSENTIAL INFORMATION). Include information for the doctor who specializes in your illness, your general doctor, and others (even if you think they will not participate, it's helpful for us to know who they are and the healthcare systems they work with, since that may provide a referral for you).*
Are any of your present doctors willing to ACT AS THE ATTENDING/PRESCRIBING DOCTOR for medical aid in dying? (PLEASE INDICATE IF YOU HAVE ASKED THEM, AND IF THEY WILL BE THE PRESCRIBING DOCTOR -- NOT ONLY IF THEY SUPPORT YOUR DECISION. Include each doctor caring for the patient.) NOTE: We cannot find a new doctor to work with your aid-in-dying request if you haven't yet asked your existing doctors to do so (unless you know specifically that they will not). Saying "I haven't asked" in response to this question will result in an email from us requiring that you ask.*
Are any of your present doctors willing to act as the consulting/2nd-opinion doctor for medical aid in dying? (PLEASE INDICATE IF YOU HAVE ASKED THEM, AND IF THEY HAVE AGREED TO OR DECLINED YOUR REQUEST. Include each doctor caring for the patient.) NOTE: We cannot find a new doctor to work with your aid-in-dying request if you haven't yet asked your existing doctors to do so (unless you know specifically that they will not). Saying "I haven't asked" in response to this question will result in an email from us requiring that you ask.*
Possible timing of taking aid-in-dying medications to die? Days, weeks, or months away? Or, you are only considering the possibility, the timing is unknown. (If you are filling out this form for the patient and do not know the answer to this, please talk with the patient about it.)*
Any special communication needs?
How did you learn about this form and referral system?
Consent to the ACAMAID Patient-to-Doctor Referral Program*
I have read and agree to ACAMAID's Referral Policy as noted below
ACAMAID has confirmed that the physicians in our referral system are licensed with their state Medical Board. ACAMAID and/or its representatives do not otherwise vet or review these physicians. We are not in any way responsible for the care they provide, and our role ends with the completion of the referral. By checking that you have consented to our referral system, you agree that you will not hold ACAMAID or its representatives responsible for any actions or omissions of the referred physician. ACAMAID's role is solely that of a referral system and not that of a health care provider. Submitting this form is your permission for us to share your information with potential aid-in-dying physicians and other related health care providers who may participate in your evaluation for and/or care related to medical aid in dying.

If you enter “Submit” and are not taken to the confirmation page, you have left required fields blank and we will not receive your form. Please fill in the missing fields and then re-submit the form.