Fill and Sign the 372 1103 Emergency Custody Orders for Adult Persons Who Form

MEDICAL EMERGENCY CUSTODY PETITION Case No. ........................................................................ Commonwealth of Virginia VA. CODE § 37.2-1103 [ ] General District Court ............................................................................................................................................................................ [ ] Circuit Court CITY OR COUNTY ......................................................................................................................................................................................................................................................................... NAME OF RESPONDENT ADDRESS OF RESPONDENT I, .............................................................................................................................................................. , a licensed physician, state that: NAME OF PHYSICIAN I have communicated with the emergency medical services pe rsonnel on the scene and attempted to communicate with the respondent to obtain information and medical data concerning the cause of the respondent’s incapacity. I attempted to obtain consent of the respondent for treatment of the following mental or physical disorder ......................................................................................................................................................................................................................................................................... and have failed to obtain such consent. The respondent is within the judge’s or magistrate’s jurisdiction at ......................................................................................................................................................................................................................................................................... NAME AND ADDRESS OF LOCATION OF RESPONDENT In my opinion, the respondent is incapable of making an informed decision on treatment of the abo ve-described mental or physical disorder, has refused transport to obtain treatment, has indicated an intention to resist transport, and is unlikely to become capable of making an informed decision on obtaining necessary treatment within the time required for suc h decision because of: [ ] the following physical injury or illness: ................................................................................................................................................................................ [ ] an undiagnosed physical injury or illness whose symptoms are: ......................................................................................................................................................................................................................................................................... I understand that a person with dysphasia or other communication disorder who is mentally compet ent and able to communicate shall not be considered incapable of giving informed consent by law and the respondent is no t such a person to the best of my knowledge. The medical standard of care indicates that the following testing, observation or treatment of the above-described disorder sho uld be provided to prevent imminent and irreversible harm: ......................................................................................................................................................................................................................................................................... (Check and complete if applicable) [ ] The respondent does not desire testing, observation or treatment because of the following religious beliefs or basic values: ......................................................................................................................................................................................................................................................................... ................................................................................. ___________________________________________________________________ DATE AND TIME PHYSICIAN’S SIGNATURE [ ] Oral petition by above-named physician, who agreed with this transcription when it was read back to him. ................................................................................. ___________________________________________________________________ DATE AND TIME SIGNATURE OF MAGISTRATE FORM DC-491 MASTER 11/10