Sec. 7. (a) The state department shall prepare a form for a patient to use to request administration of chymopapain. The form must be substantially in the following form: REQUEST FOR ADMINISTRATION OF CHYMOPAPAIN FOR MEDICAL TREATMENT Patient's name _______________________________ Address _____________________________________ Age ___________ Sex ____________ Name and address of administering physician _____________________________________________ Physical condition diagnosed for medical treatment by chymopapain _____________________________________________ _____________________________________________ My physician has explained the following to me: (1) That the manufacture and distribution of chymopapain has been banned by the federal Food and Drug Administration. (2) That there are alternative recognized treatments for the back ailment from which I suffer that my physician has offered to provide for me, including the following: (Here describe) ____________________________________________ ____________________________________________ Notwithstanding this explanation, I request the administration of chymopapain in the medical treatment of the back ailment from which I suffer. _______________________________________ Patient or person signing for patient ATTEST: ______________________________________ Prescribing physician (b) A copy of the request form shall be sent immediately after execution to the state department. [Pre-1993 Recodification Citation: 16-8-10-5.]
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