Seeking a place to die
If you are in need of a safe location to exercise your end of life choice of Medical Aid in Dying (MAID) or Voluntary Stopping of Eating and Drinking (VSED) please complete this form. Please understand these are not medical facilities, but rooms in the homes of community members. These spaces are not supported with medical personal, but trained community care volunteers.
Email address *
I would like to exercise my choice
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Guest Name *
Guest Phone Number *
City
Guest Support Person if applicable
Guest Support Person phone number
Diagnosed Illness *
Are you under a physician's care? if so please write their name and phone number below
Choice in which you want to exercise *
Have you been approved for Medical Aid in Dying?
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Are you under hospice care?
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If yes, which Hospice
Do you have your advance care documents completed?
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Do you have your disposition plans completed?
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I understand
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