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:
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.
K.S.A. 65-6b05