1. (a) The state department shall prepare a form for a patient to use to request administration of chymopapain. The form must be substantially in the following form:

Patient's name _______________________________

1. (1) That the manufacture and distribution of chymopapain has been banned by the federal Food and Drug Administration.

2. (2) That there are alternative recognized treatments for the back ailment from which I suffer that my physician has offered to provide for me, including the following: (Here describe)

   ____________________________________________

   ____________________________________________

   Notwithstanding this explanation, I request the administration of chymopapain in the medical treatment of the back ailment from which I suffer.

Address _____________________________________

Age ___________ Sex ____________

Name and address of administering physician

_____________________________________________

Physical condition diagnosed for medical treatment by chymopapain

_____________________________________________

_____________________________________________

My physician has explained the following to me:

ATTEST:

1. (b) A copy of the request form shall be sent immediately after execution to the state department.

   [Pre-1993 Recodification Citation: 16-8-10-5.]

______________________________________

Prescribing physician

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