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End of Life Washington
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Full Instructions

Request for Death with Dignity Support

If you are seeking Death with Dignity and qualify to use the law (6 month prognosis, Washington State resident, over age 18) please complete this form to be assigned a Volunteer Client Adviser, who will reach out to you within 24 to 48 hours after your form is submitted.

Death with Dignity Support Form

  • Are you currently on hospice? * Required
    [If not, End of Life Washington highly recommends you seek referral to hospice if you are seeking Death with Dignity.]
  • [In order to qualify for Death with Dignity, you must have a prognosis of 6 months or less.]
  • Have you made a first oral request to a physician? * Required
    [The first oral request is made when you inform a physician that you want Death with Dignity as an option at end of life AND the physician writes your request in your record. This starts the 15-day waiting period required by law.]
  • [Include the name of the physician to whom you made your first oral request, as well as your primary care physician and any specialists familiar with your disease and its prognosis.]
    NameField of Medicine 
    Add a new row
  • NameRelationship 
    Add a new row
  • [If someone other than yourself, please provide contact information.]
    NamePhoneEmail

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