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. ________________________________________________________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.]As added by P.L.2-1993, SEC.25.
Indiana Legal Code