67Contact person appointment form

#### 67 Contact person appointment form 67 Contact person appointment form > > (1) The appointment of a contact person by the patient must be made in the approved form (the contact person appointment form) and include the following— > > > > > (a) the patient’s name, date of birth and contact details, > > > > > (b) the name and contact details of the coordinating practitioner for the patient, > > > > > (c) the contact person’s name, date of birth and contact details, > > > > > (d) a statement that the contact person consents to the appointment, > > > > > (e) a statement that the contact person understands the person’s role under this Act, including— > > > > > > > (i) that the contact person agrees to comply with guidelines issued by the Health Secretary under section 181(2)(d), and > > > > > > > (ii) the requirements under section 125 and the penalties for contravening the requirements, > > > > > (f) if the patient was assisted by an interpreter when making the appointment, the interpreter’s name, contact details and accreditation details, > > > > > (g) the contact person’s signature and the date the form was signed, > > > > > (h) the patient’s signature, or the signature of the other person who completes the form on behalf of the patient, and the date the form was signed. > > > (2) Another person may complete the form on behalf of the patient if— > > > > > (a) the patient is unable to complete the contact person appointment form, and > > > > > (b) the patient directs the person to complete the contact person appointment form, and > > > > > (c) the person is an adult. > > > (3) The patient or the patient’s contact person must give the contact person appointment form to the patient’s coordinating practitioner. > > > (4) Within 5 business days after receiving the contact person appointment form, the patient’s coordinating practitioner must give a copy of the form to the Board. > > > > Maximum penalty—100 penalty units. > > > (5) The patient’s coordinating practitioner must not prescribe a voluntary assisted dying substance for the patient before the contact person appointment form is given to the coordinating practitioner.