4. The information constituting the component referred to in paragraph 2 of section 2 is the following:(1) the record number of the person who requested medical aid in dying in the institution or the private health facility in which the competent professional who administered medical aid in dying practises and in which the notes concerning medical aid in dying are recorded, as well as the identification of the institution or private health facility concerned and of the institution’s facility concerned, if applicable;
(2) concerning the competent professional who administered medical aid in dying:(a) the competent professional’s name and signature;
(b) the number of the competent professional’s licence to practise;
(c) professional contact information;
(3) concerning the second competent professional consulted:(a) the competent professional’s name;
(b) the number of the competent professional’s licence to practise;
(c) professional contact information.