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Forms Received
Washington Death with Dignity Act Forms Received by the Department of Health
| DOH Publication Number | Form Name | 2009 | 2010 | 2011 |
|---|---|---|---|---|
| 422-063 | Written Request for Medication to End My Life in a Humane and Dignified Manner form | 64 | 95 | 71 |
| 422-064 | Attending Physician's Compliance form | 65 | 100 | 70 |
| 422-065 | Consulting Physician's Compliance form | 67 | 103 | 69 |
| 422-066 | Psychiatric/Psychological Consultant's Compliance form | 4 | 2 | 5 |
| 422-067 | Pharmacy Dispensing Record form | 63 | 86 | 67 |
| 422-068 | Attending Physician's After Death Reporting form | 42 | 75 | 80 |