The “written informed request” referred to in this act shall be on a form prepared by, and obtained from the state board of healing arts and shall be in substance as follows:

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 its use as a dietary supplement:

________________________________________

________________________________________

My physician has explained to me:

(a) That the federal food and drug administration has determined amygdalin (laetrile) to be an “unapproved new drug” and that federal law prohibits the interstate distribution of an “unapproved new drug.”

(b) That neither the American cancer society, the American medical association, the Kansas medical society nor the Kansas association of osteopathic medicine recommends use of amygdalin (laetrile) in the treatment of any malignancy, disease, illness or physical condition.

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

________________________________________

________________________________________

That notwithstanding the foregoing, I hereby request prescription and use of amygdalin (laetrile) (a) in the medical treatment of the malignancy, disease, illness or physical condition from which I suffer [ ], (b) as a dietary supplement [ ] or (c) both in the medical treatment of the malignancy, disease, illness or physical condition from which I suffer and as a dietary supplement [ ] (check (a), (b) or (c)).

_____________________________________ Patient or person signing for patient

ATTEST:

_____________________________________

  Prescribing Physician

A copy of such written informed request shall be forwarded forthwith after execution thereof to the medical care facility or other health care facility and the state board of healing arts.