Clinicians Hotline Data Form

Hotline Data Form

MM slash DD slash YYYY
If by phone or text, the time (approximately) it was received. (Use time zone of receiving clinician.)
:
MM slash DD slash YYYY
Name of person calling or emailing
This question was (pick one)
Discussed with or Forwarded to Backup Clinician

Teaching and supporting best practices for the care of patients considering or completing medical aid in dying.

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