Certification of Illness and Medical Waiver

Certification of Illness and Medical Waiver

Healthcare Provider Certification of Terminal Illness and Medical Clearance to be completed by Physician / Provider
Patient Information
My Final Wish Applicant’s Name (the “Wish Applicant”):*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Medical Provider Information
Physician Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Medical License Number*
License Issuing State*
Patient Medical Information
Wish Applicant’s Diagnosis(es): *
Other Comorbidities: *
Functional Status measured in Karnofsky Performance Status or ECOG: *
Does the Wish Applicant have any special medical needs, such as oxygen or equipment, that require special accommodations during their Wish?*

YESNO
If YES, please provide a detailed list:
Does the Wish Applicant have the cognitive capacity to participate in their Wish in a meaningful way?*

YESNO
If No, please explain below:
Does the Wish Applicant have a prognosis of six (6) months or less OR would not be able to actively participate in the requested Wish beyond the next six (6) months?*

YesNoUncertain
If No or Uncertain, please explain below:
I, {physicianName}, certify that I am the treating physician of the Wish Applicant. To the best of my knowledge, my patient, the Wish Applicant, has a life expectancy of six (6) months or less OR my patient could not actively participate in the requested Wish beyond the next six (6) months. I certify that my patient is of sound mind, and capable of signing legal documents. I have discussed the Wish request with my patient and have deemed it safe and reasonable if his/her Wish is granted within the next (3) three months.
Physician Signature*

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Certification of Illness and Medical Waiver

Patient Information

Medical Provider Information

Patient Medical Information