Voluntary Assisted Dying Regulation 2025

the name, date of birth, home address and telephone number of the individual;

the condition the individual intends to rely on in making a request to access voluntary assisted dying;

the date the condition mentioned in paragraph (b) was diagnosed;

1 of the following:

the name of the health practitioner who diagnosed the condition mentioned in paragraph (b);

the address of the place where the condition mentioned in paragraph (b) was diagnosed;

the name and business address of the individual’s treating health practitioner;

if the individual has a coordinating practitioner—the name, business address and telephone number of the coordinating practitioner;

if the individual intends to rely on a family member, friend or carer living in the ACT to demonstrate their substantial connection to the ACT—

the name, telephone number and home address of the family member, friend or carer; and

a statement about whether the individual intends to live with the family member, friend or carer;

a statement about whether the individual intends to make a practitioner administration decision or self‑administration decision;

if the individual intends to make a self-administration decision—the address where the individual intends to—

store any approved substance prescribed to the individual before self-administration; and

self-administer any approved substance prescribed to the individual;

if the individual intends to make a practitioner administration decision—the address of the place where the individual intends to be administered any approved substance prescribed to the individual;

the address in the ACT where the individual intends to receive treatment for the condition mentioned in paragraph (b).