Fill and Sign the Petition Requesting Authorization for Medical Treatment of Juvenile Form

PETITION REQUESTING AUTHORIZATION FOR MEDICAL TREATMENT OF JUVENILE COMMONWEALTH OF VIRGINIA VA. CODE ANN. §§ 16.1-241, 16.1-262, 54.1-2969 Rules 8:3, 8:22 Case File. Juvenile and Domestic Relations District Court In re a Child under eighteen years of age , its , by NAME OF AGENT FOR HOSPITAL OR MEDICAL FACILITY TITLE , and ADDRESS OF HOSPITAL OR MEDICAL FACILITY M.D. are the petitioners NAME AND ADDRESS OF PHYSICIAN representing to the Court, under oath, the following: 1. The above-named physician is familiar with the present physical conditio\ n of the juvenile and the circumstances surrounding the juvenile, and the physician has examined the juvenile an\ d found the juvenile demonstrating the following symptoms: 2. The physician has made the following diagnosis regarding the juvenile: 3. Your petitioners, respectively, recommend and are willing to provide the\ following necessary medical, surgical and nursing care if judicial consent is given as requested: further diagnostic testing, namely: PETITION REQUESTING AUTHORIZATION FOR MEDICAL TREATMENT OF JUVENILE FORM DC-550 (PAGE ONE OF TWO) 7/ 92 PDF NAME OF HOSPITAL OR MEDICAL FACILITY , 1. CHILD'S NAME 3. DATE OF BIRTH 2. SOCIAL SECURITY NO. 5. CHILD EVER MARRIED? SEX: 4. AGE: YES NO M. F. 6. CHILD'S ADDRESS TELEPHONE NO. 7. FATHER'S NAME TELEPHONE NO. 8. FATHER'S ADDRESS 9. MOTHER'S NAME TELEPHONE NO. 10. MOTHER'S ADDRESS 11. GUARDIAN/ LEGAL CUSTODIAN OR PERSON IN LOCO PARENTIS 12. ADDRESS TELEPHONE NO. 13. NAME OF NEAREST RELATIVE IF PARENTS OR GUARDIAN CANNOT BE FOUND TELEPHONE NO. 14. ADDRESS treatment namely: 4. The petitioners further represent that the juvenile is within the cit\ y or county named above and is subject to the jurisdiction of this Court. Judicial consent for the above emergency\ surgical and medical treatment is necessary because the consent of the juvenile's parent, guardian, legal \ custodian or other person standing in loco parentis is unobtainable in that: such person is not a resident of this State. such person's whereabouts are unknown. such person cannot be consulted with promptness reasonable under the cir\ cumstances. such person fails to give such consent or provide such treatment when re\ quested by the Judge to do so. Your petitioners request that the Court grant consent to medical, surgic\ al and nursing care and treatment as described in the petition. The Petitioners further request that the Cour\ t order that the parent or other person responsible for the care and support of the juvenile be responsible to p\ ay the expenses thereof. NAME OF HOSPITAL OR MEDICAL FACILITY DATE By: SIGNATURE OF DULY AUTHORIZED AGENT OF HOSPITAL OR MEDICAL FACILITY Sworn/affirmed and signed before me on DATE DATE SIGNATURE PHYSICIAN'S SIGNATURE NAME OF PHYSICIAN Sworn/affirmed and signed before me on DATE DATE SIGNATURE NOTICE: Rule 8.22 requires that: 1. Any request for judicial consent for emergency medical, surgical or n\ ursing care MUST be filed in the clerk's office of the juvenile and domestic relations district court wit\ hin 5 calendar days from the date of granting such consent. 2. If the request was made orally, it must be reduced to writing and fil\ ed as described above. FORM DC-550 (PAGE TWO OF TWO) 12/99 PDF