ORS 127.897
§6.01. Form of the request


A request for a medication as authorized by ORS 127.800 (§1.01. Definitions) to 127.897 (§6.01. Form of the request) shall be in substantially the following form:

I, ______________________, am an adult of sound mind.
I am suffering from _________, which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care and pain control.
I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.
INITIAL ONE:
______ I have informed my family of my decision and taken their opinions into consideration.
______ I have decided not to inform my family of my decision.
______ I have no family to inform of my decision.
I understand that I have the right to rescind this request at any time.
I understand the full import of this request and I expect to die when I take the medication to be prescribed. I further understand that although most deaths occur within three hours, my death may take longer and my physician has counseled me about this possibility.
I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.
Signed: _______________
Dated: _______________
We declare that the person signing this request:

(a)

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

(b)

Signed this request in our presence;

(c)

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

(d)

Is not a patient for whom either of us is attending physician.
______________ Witness 1/Date
______________ Witness 2/Date
NOTE: One witness shall not be a relative (by blood, marriage or adoption) of the person signing this request, shall not be entitled to any portion of the person’s estate upon death and shall not own, operate or be employed at a health care facility where the person is a patient or resident. If the patient is an inpatient at a health care facility, one of the witnesses shall be an individual designated by the facility.

[1995 c.3 §6.01; 1999 c.423 §11]

Source: Section 127.897 — §6.01. Form of the request, https://www.­oregonlegislature.­gov/bills_laws/ors/ors127.­html.

127.002
Definitions for ORS 127.005 to 127.045
127.005
When power of attorney in effect
127.015
Revocation of power of attorney
127.025
Authority under power of attorney recognizable regardless of date of execution
127.035
Limitations on liability of person reasonably relying on power of attorney
127.045
Duty of agent under power of attorney
127.505
Definitions for ORS 127.505 to 127.660
127.507
Capable adults may make own health care decisions
127.510
Appointment of health care representative and alternate health care representative
127.515
Execution
127.520
Persons not eligible to serve as health care representative
127.525
Acceptance of appointment
127.527
Form for appointing health care representative
127.529
Form of advance directive
127.532
Appointment
127.533
Duties
127.535
Authority of health care representative
127.540
Limitations on authority of health care representative
127.545
Revocation of advance directive or health care decision
127.550
Petition for judicial review of advance directives
127.555
Designation of attending physician or health care provider
127.560
Provisions not exclusive
127.565
Independent medical judgment of provider
127.570
Mercy killing
127.575
Instrument presumed valid
127.580
Presumption of consent to artificially administered nutrition and hydration
127.625
Providers under no duty to participate in withdrawal or withholding of certain health care
127.635
Withdrawal of life-sustaining procedures
127.640
Physician to determine that conditions met before withdrawing or withholding certain health care
127.642
Principal to be provided with certain care to insure comfort and cleanliness
127.646
Definitions for ORS 127.646 to 127.654
127.649
Health care organizations required to have written policies and procedures on providing information on patient’s right to make health care decisions
127.652
Time of providing information
127.654
Scope of requirement
127.658
Effect of ORS 127.505 to 127.660 on previously executed advance directives
127.660
Short title
127.663
Definitions for ORS 127.663 to 127.684
127.666
Establishment of registry
127.669
Oregon Health Authority not required to perform certain acts
127.672
POLST not required
127.678
Confidentiality
127.681
Immunity from liability
127.684
Short title
127.700
Definitions for ORS 127.700 to 127.737
127.702
Persons who may make declaration for mental health treatment
127.703
Required policies regarding mental health treatment rights information
127.705
Designation of attorney-in-fact for decisions about mental health treatment
127.707
Execution of declaration
127.710
Operation of declaration
127.712
Scope of authority of attorney-in-fact
127.715
Prohibitions against requiring person to execute or refrain from executing declaration
127.717
Declaration to be made part of medical record
127.720
Circumstances in which physician or provider may disregard declaration
127.722
Revocation of declaration
127.725
Limitations on liability of physician or provider
127.727
Persons prohibited from serving as attorney-in-fact
127.730
Persons prohibited from serving as witnesses to declaration
127.732
Withdrawal of attorney-in-fact
127.736
Form of declaration
127.737
Certain other laws applicable to declaration
127.760
Consent to health care services by person appointed by hospital
127.765
Health care advocate
127.800
§1.01. Definitions
127.805
§2.01. Who may initiate a written request for medication
127.810
§2.02. Form of the written request
127.815
§3.01. Attending physician responsibilities
127.820
§3.02. Consulting physician confirmation
127.825
§3.03. Counseling referral
127.830
§3.04. Informed decision
127.835
§3.05. Family notification
127.840
§3.06. Written and oral requests
127.845
§3.07. Right to rescind request
127.850
§3.08. Waiting periods
127.855
§3.09. Medical record documentation requirements
127.860
§3.10. Residency requirement
127.865
§3.11. Reporting requirements
127.870
§3.12. Effect on construction of wills, contracts and statutes
127.875
§3.13. Insurance or annuity policies
127.880
§3.14. Construction of Act
127.885
§4.01. Immunities
127.890
§4.02. Liabilities
127.892
Claims by governmental entity for costs incurred
127.895
§5.01. Severability
127.897
§6.01. Form of the request
127.995
Penalties
Green check means up to date. Up to date