Forms for Medical Assistance in Dying

HLTH 1632

The form for a person to submit their request for medical assistance in dying.
For more information on submitting the Request for Medical Assistance in Dying form, see the Medical Assistance in Dying page.

• Request for Medical Assistance in Dying (PDF, 725 KB)
• Instructions for Request for Medical Assistance in Dying (PDF, 288 KB)

HLTH 1632
LARGE PRINT

The form for a person to submit their request for medical assistance in dying. This form is in large 14pt type.
For more information on submitting the Request for Medical Assistance in Dying form, see the Medical Assistance in Dying page.

• Request for Medical Assistance in Dying, Large Print (PDF, 724 KB)
• Instructions for Request for Medical Assistance in Dying (PDF, 288 KB)

HLTH 1645

The form for a person to waive the requirement to give express consent immediately prior to receiving medical assistance in dying. Please consult with your doctor or nurse practitioner, regarding whether you meet the criteria to waive final consent.
For more information on the condition under which the Waiver of Final Consent may be used, see the Medical Assistance in Dying page.

• Waiver of Final Consent (PDF, 1.1 MB)
• Instructions for Request for Waiver of Final Consent (PDF, 222 KB)

Medical Assistance in Dying Care Coordination Service
Interior Health Community Health and Services Centre
505 Doyle Avenue, 3rd Floor
Kelowna BC  V1Y 0C5

HLTH 1633

For the assessing medical or nurse practitioner to record details of their assessment of a patient’s eligibility for medical assistance in dying.

• Assessment Record (Assessor) (PDF, 2.1 MB)*
• Instructions for Assessment Record (Assessor) (PDF, 322 KB)
• * If the patient has completed a request on an old 1632 form (form version prior to
  Dec 28, 2022), please ensure they complete the 1632a – Additional Information Attachment.

HLTH 1634

For the prescribing medical or nurse practitioner to record details of their assessment of a patient’s eligibility and details related to the planning and administration of medical assistance in dying.

• Assessment Record (Prescriber) (PDF, 2.2 MB)*
• Instructions for Assessment Record (Prescriber) (PDF, 389 KB)
• * If the patient has completed a request on an old 1632 form (form version prior to
  Dec 28, 2022), please ensure they complete the 1632a – Additional Information Attachment.

For a consulting practitioner to record details of their assessment of a patient’s capability to make an informed consent decision regarding medical assistance in dying. (To be used only if one or both assessors have reason to be concerned regarding a patient's capability to provide informed consent.)

Note: This form is only for an assessment of capability to give informed consent. This form is not required for a consultation with a doctor or nurse practitioner with expertise in the condition causing the patient’s suffering.

• Consultant's Assessment of Patient's Informed Consent Decision Capability (PDF, 703 KB)
• Instructions for Consultant's Assessment of Patient's Informed Consent Decision Capability (PDF, 212 KB)

Prescription and Medication Administration Record

• The BC Medical Assistance in Dying Prescription form (including the Pre-Printed Order and the Medication Administration Record) and the British Columbia Pharmacy Protocols guidance document are not available for general distribution. These documents can be accessed by the prescribing practitioner through the College of Physicians and Surgeons of British Columbia or through each health authority’s Care Coordination Centre.

Fraser Health
Interior Health
Island Health
Northern Health
Provincial Health Services Authority
Vancouver Coastal Health

Medical Certification of Death - Vital Statistics Agency

• A medical or nurse practitioner must complete the Medical Certification of Death within 48 hours of death in compliance with Section 18 of the Vital Statistics Act and provide the completed form to the Funeral Director so that a Disposition Permit may be issued.
  To order additional VSA 406A forms, fax or email the Vital Statistics Agency. Stockroom Fax: 250 952-9094. Email: HLTH.VSstock@gov.bc.ca

Reporting Submission Checklist (Optional)

• Practitioners and pharmacists can also view the MAiD Reporting at a Glance one-page reference sheet for details on forms submission.
• HLTH 1646 Reporting Submission Checklist (778 KB).

• This form has been retired. Practitioners who transfer a patient's request for MAiD to another practitioner or health authority MAiD Care Coordination Service (without conducting an assessment of the patient's eligibility) are no longer required to report. 

HLTH 1641

For the pharmacist who dispenses a substance in connection with the provision of medical assistance in dying, to record details pertaining to the dispensing and return of unused medications.

• Dispensing Record (Pharmacist) (PDF, 724 KB)
• Instructions for Dispensing Record (PDF, 235 KB)

For the Coordinator of a health authority’s MAiD Care Coordination Service to complete and submit to Rural Programs, Ministry of Health, to request funding approval for a physician to travel to a rural/isolated community to conduct an eligibility assessment or provide medical assistance in dying.

(Note:  Funding request may include a mentorship training opportunity for local physician(s) willing to train with visiting physician in assessment or provision of MAiD.)

• MAiDTTAP Funding Request (PDF, 684 KB)

For the visiting physician to complete and submit to Rural Programs, Ministry of Health, for reimbursement of travel costs and travel related expenses for approved travel to a rural/isolated community to conduct an eligibility assessment or provide medical assistance in dying.

(Note:  Travel approval is sought by the health authority’s MAiD Care Coordination Service, using the HLTH 1638 form.)

• MAiDTTAP Application for Expenses (PDF, 590 KB)

For a local physician to complete and submit to Rural Programs, Ministry of Health, to receive payment for participating in an approved mentored training opportunity with a visiting physician in eligibility assessment or provision of medical assistance in dying.

(Note:  Training approval is sought by the health authority’s MAiD Care Coordination Service, using the HLTH 1638 form.)

• MAiDTTAP Application for Mentorship Training Payment (PDF, 532 KB)

For the Coordinator of a health authority’s MAiD Care Coordination Service to complete and submit to Rural Programs, Ministry of Health, to request Vising Mentor funding approval for a physician to travel to a rural/isolated community to provide support and mentorship to the Local Physician's first provisions.​

(Note: Funding request is only for MAiD Visiting Mentors who are providing support and mentorship. For MAiD physicians providing assessment or provision, please use form HLTH 1638.)​

• MAiDTTAP Visiting Mentor Funding Request (PDF, 684 KB)