Sign the declaration (physicians)

Copy of Manifeste docteur FR

This form is only for physicians who wish to sign the declaration.

If you are a concerned citizen, you may support the declaration here.

I am signing the declaration of the Physicians' Alliance against euthanasia *

Yes No

Prefix *

First name *

Middle name

Last name *

Suffix

Email *

Phone

Address *

Address (additional field)

City *

Postal code *

Province *

Country *

Preferred language *

I consent to my name appearing publicly on the list of signatures *

Yes No

License number *

Specialty *

Email list with moderate traffic

Newsletter *

Yes No

Email list with occasional traffic

Urgent calls to action *

Yes No

No bulk email

Cancel