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Medical Authorization JD-1734 - Wisconsin
|Medical Authorization Form. This is a Wisconsin form and can be used in Juvenile Circuit Court Statewide .||
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FORM SUMMARY Name of Form: Form Number: Statutory Reference: Benchbook Reference: Medical Authorization JD-1734 §§48.373, 938.373, 938.296(4) JV 1 Purpose of Form: Court authorization, with child/juvenile's consent, for medical treatment Party seeking the court's approval for the medical treatment Original to court, copy (certified or authenticated) to treatment facility Generally none, although medical reports detailing the condition and need for treatment may be attached Modification, last update 4/97. Added a file/date stamp to upper right corner. Added a statement on the bottom indicating that the form shall not be modified. This form cannot be used for testing for HIV/STD under chapter 48. Such testing was repealed for ch. 48. It can be used for chapter 938 cases pursuant to §938.296(4). This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Who Completes It: Distribution of Form: Accompanying Forms: New Form/Modification: Modifications: Comments: About this form: Date: 05/31/00 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use STATE OF WISCONSIN, CIRCUIT COURT, IN THE INTEREST OF COUNTY Medical Authorization Name Case No. Date of Birth THE COURT FINDS: 1. The child/juvenile is within the jurisdiction of this court. 2. Reasonable cause exists for these services. 3. The child/juvenile consents to the medical and/or surgical procedures requested. The court authorizes the following medical and/or surgical procedures: BY THE COURT: Signature of Circuit Court Judge Name Printed or Typed Date Consent of Child/Juvenile I consent to the medical and/or surgical procedures requested. Signature of Child/Juvenile/GAL Name Printed or Typed Date JD-1734, 05/00 Medical Authorization Page 1 of 1 §§48.373, 938.373, 938.296(4), Wisconsin Statutes. American LegalNet, Inc. www.FormsWorkflow.com This form shall not be modified. It may be supplemented with additional material.