(name and address) ….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….…. 10 ….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….…. 1 1 I declare that I am eligible to be lawfully provided with assistance to end my own life under the Assisted Dying for Terminally Ill Adults (Scotland) Act 2024 and that I wish to be provided with that assistance. 2 I understand that the assistance can be provided only if I have made a first declaration, 15 have been assessed as eligible by two registered medical practitioners who have completed medical assessment forms under the Act, and have made this second declaration. 3 I make this declaration voluntarily and, in particular, I have not been coerced or pressured by any other person into making it. 20 4 I understand I can cancel this declaration at any time. 5 I am registered as a patient with the above medical practice. 6 I am aged 18 or over. 23 Signed: Dated: Coordinating registered medical practitioner: 25 25 ….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….….…. Name: 26...