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Any physician who is in agreement with the concept of euthanasia may sign this form.
Name of Physician:
Practice Address:
Phone Number:
Email Address:
Do you hereby consent to the practice of euthanasia?
Do you understand that by signing this form, you are consenting to the practice of euthanasia and are therefore legally responsible for any and all actions taken as a result of this consent?
Signature of Physician:
Date: