1. (1) A request for medical aid-in-dying medication authorized by this article 48 must be in substantially the following form:

   Request for medication to end my life

   in a peaceful manner

   I, am an adult of sound mind. I am suffering from , which my attending provider has determined is a terminal illness and which has been medically confirmed. I have been fully informed of my diagnosis and prognosis of six months or less, the nature of the medical aid-in-dying medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment opportunities, including comfort care, palliative care, hospice care, and pain control.

   I request that my attending provider prescribe medical aid-in-dying medication that will end my life in a peaceful manner if I choose to take it, and I authorize my attending provider to contact any pharmacist about my request.

   I understand that I have the right to rescind this request at any time.

   I further understand that although most deaths occur within three hours, my death may take longer, and my attending provider has counseled me about this possibility. I make this request voluntarily, without reservation, and without being coerced, and I accept full responsibility for my actions.

   Signed:

   Dated:

   Declaration of witnesses

   We declare that the individual signing this request:

   Is personally known to us or has provided proof of identity;

   Signed this request in our presence;

   Appears to be of sound mind and not under duress, coercion, or undue influence; and

   I am not the attending provider for the individual.

   witness 1/date

   witness 2/date

   Note: Of the two witnesses to the written request, at least one must not:

   Be a relative (by blood, marriage, civil union, or adoption) of the individual signing this request; be entitled to any portion of the individual's estate upon death; or own, operate, or be employed at a health-care facility where the individual is a patient or resident.

   And neither the individual's attending or consulting provider nor a person authorized as the individual's qualified power of attorney or durable medical power of attorney shall serve as a witness to the written request.

Source: Initiated 2016: Entire article added, Proposition 106, L. 2017, p. 2809, § 1, effective upon proclamation of the Governor, December 16, 2016. L. 2024: Entire section amended, (SB 24-068), ch. 406, p. 2795, § 11, effective August 7.