1. (a) The written informed request must be on a form prepared by and obtained from the medical licensing board of Indiana and must be in substance as follows:

   1. (1) That the manufacture and distribution of amygdalin (laetrile) has been banned by the Federal Food and Drug Administration.
   2. (2) That neither the American Cancer Society, the American Medical Association, nor the Indiana State Medical Association recommend use of amygdalin (laetrile) in the treatment of a malignancy, a disease, an illness, or a physical condition.

   3. (3) That there are alternative recognized treatments for the malignancy, disease, illness, or physical condition from which I suffer that my physician has offered to provide for me, including the following:

      (Here describe)

      ______________________________________

      ______________________________________

      Notwithstanding this explanation, I request prescription and use of amygdalin (laetrile):

   4. (1) in the medical treatment of the malignancy, disease, illness, or physical condition from which I suffer ( ); or

   5. (2) as a dietary supplement ( ).

      (Check (1) or (2))

      ________________________________________

      Patient or person signing for patient

      ATTEST:

      __________________________________

      Prescribing physician

   WRITTEN INFORMED REQUEST

   FOR PRESCRIPTION OF AMYGDALIN

   (LAETRILE) FOR MEDICAL

   TREATMENT

   Patient's name __________________________

   Address _________________________________

   Age ________ Sex ___________

   Name and address of prescribing physician

   _________________________________________

   Malignancy, disease, illness, or physical condition diagnosed for medical treatment by amygdalin (laetrile) or the use of amygdalin as a dietary supplement:

   ________________________________________

   ________________________________________

   My physician has explained the following to me:

2. (b) A copy of the written informed request shall be forwarded after execution to the medical licensing board of Indiana for appropriate filing.

   [Pre-1993 Recodification Citation: 16-8-8-5.]

As added by P.L.2-1993, SEC.25.