Patient Intake Form
The Academy’s Patient-to-Doctor Referral System can help connect you to clinicians who can evaluate patients for legal eligibility for medical aid in dying. We do not provide direct patient care but are here to support you with information and connect you with clinicians in your area who can evaluate you and provide aid-in-dying care. Once we identify possible providers, we will email you as quickly as possible, usually within 48 hours. Per our agreements with providers, we do NOT publicly share individual provider contact information. Once we know how to proceed, we will forward your intake form to them. We may need further information, so please check your emails often. If you haven’t heard back from us, please send an email to [email protected].
The Academy is a non-profit (501c3) and provides referrals without charge. We do gratefully accept donations to continue this service for as many as are in need, as well as our research and clinician education about medical aid in dying.
Please see our free guide for patients and their loved ones.
Please be sure to ask your present doctors about your request. If they are willing but not experienced with aid in dying, let them know that the Academy’s physicians will work with them on the details, from the law to the medications used. There is no charge for this, and they do not have to be a member of the Academy. Please share our contact information with your doctors: [email protected].
We will work diligently to refer you to providers as quickly as possible, but unfortunately, an urgent need for aid-in-dying care is typically very hard to arrange. Doctors must carefully review your medical records and confirm your eligibility, so please be prepared to help them gain access promptly.
We highly recommend you consider being admitted to hospice or stay in close touch with your providers for symptom control and contingent end-of-life care, should aid in dying become not a viable option.
The Academy provides referrals for aid-in-dying evaluations for patients whose intake form indicates they will likely meet the legal requirements. Generally, to become legally eligible for medical aid in dying, you must be an adult, live in a state where aid-in-dying is legal (or you can move to Vermont or Oregon or establish residency in an aid-in-dying state), have been diagnosed with a terminal condition with less than six months left to live, have the capacity to make your own medical decisions, and make direct uncoerced requests to medical doctors who then evaluate and confirmed these criteria. There are legally mandated waiting periods between verbal requests, and some states require a written request. Additionally, you must be able to self-ingest (orally or via feeding tube, ostomy, or rectal catheter).
Eligibility does not require proof of suffering or exact planning for self-ingestion. If you are found eligible and complete all the necessary steps, you can proceed and take the medications to die if you choose to, but you are never required to. If you are not found eligible, you may request to be closely monitored and re-evaluated if your condition changes, ideally through the same MDs who initially evaluated you.
If you ultimately proceed with self-ingestion, we strongly suggest you ensure that an experienced clinician helps manage the procedure and is at your bedside. The process can be surprisingly complex and highly stressful for patients and their grieving families to manage entirely on their own. Some organizations do not allow their staff to help mix these dangerous medications or require staff to leave their patients’ side during ingestion when families may be most in need of support. Consider your needs carefully and ask your providers for further details.
We may have referrals to hospices, independent private practice MDs, or palliative care practices that provide evaluation and aid-in-dying care. The details and cost of this care can vary. For an explanation of the models of care, please see Potential Fees and Expenses for Medical Aid in Dying.
Submitting this form grants the Academy your permission to share your information with potential aid-in-dying physicians and other related healthcare providers who may participate in your evaluation for and/or care related to medical aid in dying.
NOTE: Please pay very close attention to the details of the questions below, answer as completely as possible, and fill in the required fields (marked with *).If the form was completed and submitted correctly, you will be taken to a CONFIRMATION PAGE. If you complete this form and enter “Submit” and are NOT taken to the confirmation page, this indicates that you have left one or more *required fields blank, and we will NOT receive your form. Please go back, fill in all the missing fields and then submit the form until you DO land on the confirmation page.
~Thank you. We are happy to help. Donations gratefully accepted