Assisted Dying Bill (HL Bill 6)
SCHEDULE continued
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 correct; |
| (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 [him/her]. |
| Signature: | Date: |
| Name and Address of Independent Doctor: |