Assisted Dying Bill (HL Bill 24)

Assisted Dying BillPage 10

Signature: Date:
Name and Address of Attending Doctor:
Countersignature: Independent Doctor
I confirm that [name], who at the date of this declaration is [age] years
5of age and has been ordinarily resident in England and Wales for [time]:
(1) is terminally ill and that the diagnosis and prognosis set above is
(2) has the capacity to make the decision to end their own life; and
(3) has a clear and settled intention to do so, which has been reached on
10an informed basis, without coercion or duress, and having been
informed of the palliative, hospice and other care which is available to
Signature: Date:
Name and Address of Independent Doctor: