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Application to Authorize Medication Or Medical Procedure 50.4 - Ohio

Application to Authorize Medication Or Medical Procedure Form. This is a Ohio form and can be used in Psychiatric Probate Franklin County (Court Of Common Pleas) .
 Fillable pdf Last Modified 10/25/2013
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PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE LAWRENCE A. BELSKIS, JUDGE PC-MI-50.4 (Rev. 4/2001) IN THE MATTER OF CASE NO. APPLICATION TO AUTHORIZE MEDICATION OR MEDICAL PROCEDURE [R.C. 2101.24 and R.C 5122.271] Pursuant to R.C. 5122.271 and/or R.C 2101.24 the undersigned has information to believe or has actual knowledge that is in need of physically and is mentally unable to receive information required to give fully informed, intelligent, and knowing consent to the following procedure: As shown in Attachment A, the undersigned further states that said procedures are necessary to protect the general health and well-being of the above named person and asks that the Court authorize the above procedures. The undersigned further states that this Court has jurisdiction to hear this matter pursuant to R.C. 5122.271 and/or R.C. 2101.24. The undersigned further states that there is no guardian available to consent and attached is the opinion of the chief medical officer or attending physician and a concurring opinion by a licensed physician. APPLICANT CONCURRING OPINION FRANKLIN COUNTY FORM - 50.4-APPLICATION TO AUTHORIZE MEDICATION OR MEDICAL PROCEDURE American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. ATTACHMENT A Information necessary to provide informed consent: 1. Reason for and the nature of the proposed treatment, specifically documenting the nature, seriousness, and probable complications of the illness or disorder. [Describe behavior which demonstrates inability to care for oneself or other factual events showing behavior that is dangerous to self or others] 2. The probable degree and duration of expected improvement or remission with and without the proposed treatment. Give a history of compliance and response to past treatment. 2 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 3. Describe the specific treatment regimen, including a specific medication(s) you are seeking authority to implement. 4. The nature, degree, duration, and probability of side effects and/or significant risks. 3 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 5. A reasonable alternative treatment and reasons why the proposed treatment is recommended. APPLICANT (CHIEF CLINICAL OFFICER IF APPLICATION IS FOR SURGERY) DATE TREATING PHYSICIAN DATE 4 American LegalNet, Inc. www.FormsWorkFlow.com
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