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Medical Certificate - Ohio

Medical Certificate Form. This is a Ohio form and can be used in Juvenile Court Cuyahoga County (Court Of Common Pleas) .
 Fillable pdf Last Modified 1/20/2014
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : STATE OF OHIO COUNTY OF CUYAHOGA Index No. IN THE COMMON PLEAS COURT JUVENILE COURT DIVISION : Calendar No. : MEDICAL CERTIFICATE Plaintiff(s) -againstIN THE MATTER OF BELIEVED TO BE A ( )DEPENDENT ( )NEGLECTED CHILD JUDICIAL SUBPOENA : CASE NUMBER: : : Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.a. reputable practicing. physician, .............. 1) , a minor child born on hospital under the care of the undersigned on . deposes and says that the following statements are true to the best of his/her knowledge and belief: , was admitted to THE PEOPLE OF THE STATE OF NEW YORK TO Said child is now 2) years of age, and has been diagnosed as follows: . GREETINGS: 3) As a result of such diagnosis, the following medical and/or surgical treatment is immediately necessary in order to preserve said child=s life: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed . or adjourned date, to testify and give evidence as a witness in this action on the part of the AFFIANT Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, STATE OF OHIO COUNTY OF CUYAHOGA , one of the Justices of the day of , 20 day of Sworn to before me and subscribed in my presence this , 20 . (Attorney must sign above and type name below) Notary Public/Deputy Clerk Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com
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