CA Health & Safety Code Section 443.11

(a)

A request for an aid-in-dying drug as authorized by this part shall be in the following form:

(b)

(1)The written language of the request shall be written in the same translated language as any conversations, consultations, or interpreted conversations or consultations between a patient and his or her attending or consulting physicians.

(2)

Notwithstanding paragraph (1), the written request may be prepared in English even when the conversations or consultations or interpreted conversations or consultations were conducted in a language other than English if the English language form includes an attached interpreter’s declaration that is signed under penalty of perjury. The interpreter’s declaration shall state words to the effect that: On (insert date) at approximately (insert time), I read the “Request for an Aid-In-Dying Drug to End My Life” to (insert name of individual/patient) in (insert target language). Mr./Ms. (insert name of patient/qualified individual) affirmed to me that he/she understood the content of this form and affirmed his/her desire to sign this form under his/her own power and volition and that the request to sign the form followed consultations with an attending and consulting physician. I declare that I am fluent in English and (insert target language) and further declare under penalty of perjury that the foregoing is true and correct. Executed at (insert city, county, and state) on this (insert day of month) of (insert month), (insert year). X______Interpreter signature X______Interpreter printed name X______Interpreter address

(3)

An interpreter whose services are provided pursuant to paragraph (2) shall not be related to the qualified individual by blood, marriage, registered domestic partnership, or adoption or be entitled to a portion of the person’s estate upon death. An interpreter whose services are provided pursuant to paragraph (2) shall meet the standards promulgated by the California Healthcare Interpreting Association or the National Council on Interpreting in Health Care or other standards deemed acceptable by the department for health care providers in California.

(c)

The final attestation form given by the attending physician to the qualified individual at the time the attending physician writes the prescription shall appear in the following form:

(1)

Within 48 hours prior to the individual self-administering the aid-in-dying drug, the individual shall complete the final attestation form. If aid-in-dying medication is not returned or relinquished upon the patient’s death as required in Section 443.20, the completed form shall be delivered by the individual’s health care provider, family member, or other representative to the attending physician to be included in the patient’s medical record.

(2)

Upon receiving the final attestation form the attending physician shall add this form to the medical records of the qualified individual.