Contact | Quiĕtus | Medical Aid in Dying

New York's Medical Aid in Dying Act takes effect August 5, 2026.

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CONTACT US

Every Journey Begins With a Conversation

Whether you are seeking information for yourself, a loved one, or simply exploring your options, our team is here to listen with compassion, answer your questions, and provide guidance without pressure or obligation.

Please complete the intake form below and submit to contact our team.

Before you begin, please review our FAQ.

Patients may complete this form with help from a family member or support person. For general inquiries, please email us at info@quietus.com

First name*

Last name*

Date of birth (MM/DD/YYYY)*

Age*

Gender*

Male

Female

Address*

Apt.

City*

State*

Zip / Postal code*

Direct PHONE for patient or designated contact (not hospice/staff)*

Direct EMAIL for patient or designated contact (not hospice/staff)*

List up to 4 contacts (name and relationship to patient, phone, email) we may communicate with, besides the patient

Secondary email, in case the one above fails (not hospice/staff)*

Has the patient or their authorized representative read the Quiĕtus FAQs? If not, please review them using the link above.

Diagnosed life-limiting or terminal illness (please specify; do not include unrelated or non-terminal conditions such as mental health conditions or dementia)*

Is the patient a New York State resident?*

Yes

Is the patient enrolled in a hospice?*

Yes

Planning this soon

Which hospice is the patient enrolled in, and when did care with that hospice begin?

Has the patient ever been evaluated for medical aid in dying? If yes, please provide the provider's name, date, and outcome of the evaluation.

Mobility: Is the patient able to attend an office visit?*

Is the patient able to swallow 2–4 ounces of liquid comfortably within two minutes? (This is not required for aid in dying but helps us plan an appropriate referral)*

Yes

No, but the patient has a feeding tube

The patient will require a provider who can support with non-oral options for taking the medications

Which healthcare system or organizations have provided the patient's care in the last year? (not the insurance you use)*

Are any of the patient's current providers willing and authorized to serve as the attending/prescribing provider for medical aid in dying? (Note that "supporting" aid in dying does not indicate they are willing or authorized)*

Are any of the patient's current providers willing and authorized to serve as the consulting / second-opinion provider for medical aid in dying?*

What are the patient's thoughts on the possible timing for taking the aid-in-dying medications — days, weeks, or months away — or is the timing unknown?*

Any special communication needs?

If the patient lives in a facility, have administrators been asked about proceeding with aid in dying on the premises?

How did you learn about Quiĕtus?*

Quietus Management LLC — Intake Policy Disclaimer

By selecting "I have read and agree to Quietus Management LLC's Intake Policy," you acknowledge, understand, and agree to the following:

Quietus Management LLC ("Quietus") is a care coordination service and is not engaged in the practice of medicine or any other licensed clinical profession. No patient-physician or patient-clinician relationship is formed between you and Quietus through your submission of this form.
Quietus operates this intake and referral process as a care coordination service. Its role is limited to connecting patients and families with independent, licensed clinicians who may be able to assist with the Medical Aid in Dying process under New York law.
Quietus expressly disclaims any and all warranties, express or implied, in connection with the operation of this intake and referral process.
BY SUBMITTING THIS FORM, I HEREBY RELEASE QUIETUS MANAGEMENT LLC AND ITS FOUNDERS, OFFICERS, EMPLOYEES, CONTRACTORS, AND AFFILIATED CLINICIANS FROM ANY AND ALL LIABILITY, LOSSES, DAMAGES, CLAIMS, CAUSES OF ACTION, INTEREST, EXPENSES, COSTS, AND ATTORNEYS' FEES ARISING OUT OF OR RELATED TO MY USE OF THIS INTAKE FORM OR THE REFERRAL AND CARE COORDINATION SERVICES OF QUIETUS.
If you do not agree to these terms, please do not submit this form.

I have read and agree to Quietus Management LLC's Intake Policy

We're Here to Listen and Help

We look forward to talking to you. For inquiries, confidential consultations, or additional information, you can also contact us at: info@quietus.com

Dignity and Support at End of Life

CONTACT US

Every Journey Begins With a Conversation

We're Here to Listen and Help

We look forward to talking to you. For inquiries, confidential consultations, or additional information, you can also contact us at: info@quietus.com

SERVING NEW YORK STATE

Quiĕtus Management LLC is a care coordination service.

The information on this website is for general informational purposes only and does not constitute medical, legal, or financial advice.

© 2026 Quiĕtus Management LLC. All rights reserved

Terms of Use | Privacy Policy.

CONTACT US

Every Journey Begins With a Conversation

We're Here to Listen and Help

We look forward to talking to you. For inquiries, confidential consultations, or additional information, you can also contact us at: info@quietus.com

SERVING NEW YORK STATE

Quiĕtus Management LLC is a care coordination service.

The information on this website is for general informational purposes only and does not constitute medical, legal, or financial advice.

© 2026 Quiĕtus Management LLC. All rights reserved Terms of Use | Privacy Policy.

© 2026 Quiĕtus Management LLC. All rights reserved

Terms of Use | Privacy Policy.