Indiana Code
Chapter 24. Drugs: Use of Chymopapain
16-42-24-7. Use Request Form

Sec. 7. (a) The state department shall prepare a form for a patient to use to request administration of chymopapain. The form must be substantially in the following form:
REQUEST FOR ADMINISTRATION OF
CHYMOPAPAIN FOR MEDICAL
TREATMENT
Patient's name _______________________________
Address _____________________________________
Age ___________ Sex ____________
Name and address of administering physician
_____________________________________________
Physical condition diagnosed for medical treatment by chymopapain
_____________________________________________
_____________________________________________
My physician has explained the following to me:
(1) That the manufacture and distribution of chymopapain has been banned by the federal Food and Drug Administration.
(2) That there are alternative recognized treatments for the back ailment from which I suffer that my physician has offered to provide for me, including the following: (Here describe)
____________________________________________
____________________________________________
Notwithstanding this explanation, I request the administration of chymopapain in the medical treatment of the back ailment from which I suffer.
_______________________________________
Patient or person signing for patient
ATTEST:
______________________________________
Prescribing physician
(b) A copy of the request form shall be sent immediately after execution to the state department.
[Pre-1993 Recodification Citation: 16-8-10-5.]
As added by P.L.2-1993, SEC.25.