C.R.S. Section 25-48-112
Form of written request


A request for medical aid-in-dying medication authorized by this article must be in substantially the following form:
Request for medication to end my life
in a peaceful manner
am an adult of sound mind. I am suffering from
, which my attending physician has determined is a terminal illness and which has been medically confirmed. I have been fully informed of my diagnosis and prognosis of six months or less, the nature of the medical aid-in-dying medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment opportunities, including comfort care, palliative care, hospice care, and pain control.
I request that my attending physician prescribe medical aid-in-dying medication that will end my life in a peaceful manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.
I understand that I have the right to rescind this request at any time.
I understand the seriousness of this request, and I expect to die if I take the aid-in-dying medication prescribed.
I further understand that although most deaths occur within three hours, my death may take longer, and my attending physician has counseled me about this possibility. I make this request voluntarily, without reservation, and without being coerced, and I accept full responsibility for my actions.
Declaration of witnesses
We declare that the individual signing this request:
Is personally known to us or has provided proof of identity;
Signed this request in our presence;
Appears to be of sound mind and not under duress, coercion, or undue influence; and
I am not the attending physician for the individual.
witness 1/date
witness 2/date
Note: Of the two witnesses to the written request, at least one must not:
Be a relative (by blood, marriage, civil union, or adoption) of the individual signing this request; be entitled to any portion of the individual’s estate upon death; or own, operate, or be employed at a health-care facility where the individual is a patient or resident.
And neither the individual’s attending physician nor a person authorized as the individual’s qualified power of attorney or durable medical power of attorney shall serve as a witness to the written request.

Source: Section 25-48-112 — Form of written request, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­pdf (accessed Oct. 20, 2023).

Green check means up to date. Up to date

Current through Fall 2024

§ 25-48-112’s source at colorado​.gov