Voluntary Assisted Dying Regulations 2018

Full name:

Address:

Date of birth:

Contact details:

I, [co-ordinating medical practitioner's name], am satisfied that [name of person] has decision-making capacity in relation to voluntary assisted dying and that their request for access to voluntary assisted dying is enduring. [Name of person] is able to self‑administer and digest the poison or controlled substance or drug of dependence.

I have attached a copy of the completed final review form and all of the completed forms referred to in section 41(1)(a) of the Voluntary Assisted Dying Act 2017.

I understand that under section 87 of the Voluntary Assisted Dying Act 2017 it is a criminal offence to falsify a form or record required to be made under that Act. It is also a criminal offence under section 88 of that Act to knowingly make a false statement in a report or form that the person knows is false or misleading in a material particular. Both of these offences carry a maximum penalty of 5 years imprisonment or 600 penalty units, or both in respect of a natural person.

Date:

Signed: [co-ordinating medical practitioner]

Form 2

Regulation 6

Voluntary Assisted Dying Act 2017

APPLICATION FOR PRACTITIONER ADMINISTRATION PERMIT