Medical Emergency Temporary Detention Program {DC-489} | Pdf Fpdf Doc Docx | Virginia
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Medical Emergency Temporary Detention Program {DC-489} | Pdf Fpdf Doc Docx | Virginia

Medical Emergency Temporary Detention Program {DC-489}

This is a Virginia form that can be used for Civil within Statewide, District Court.

Alternate TextLast updated: 6/5/2007

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MEDICAL EMERGENCY TEMPORARY DETENTION PETITION Commonwealth of Virginia VA. CODE §§ 37.2-1104; 53.1-40.1(F) Case No. ............................................................................ ................................................................................................................................................................ [ CITY OR COUNTY ] General District Court [ ] Circuit Court [ ] Juvenile and Domestic Relations District Court ......................................................................................................................................................................................................................................................................... NAME OF RESPONDENT ADDRESS OF RESPONDENT I, .......................................................................................................................... , NAME OF PHYSICIAN a licensed physician, state that: I attempted to obtain consent of the above-named respondent for treatment of the following physical or mental disorder ......................................................................................................................................................................................................................................................................... The respondent is within the court's or magistrate's jurisdiction at NAME AND ADDRESS OF FACILITY ......................................................................................................................................................................................................................................................................... To the best of my knowledge, the respondent is incapable of making an informed decision, or is incapable of communicating such a decision, on treatment of the above-described physical or mental disorder because of: [ ] the following physical or mental disorder: .................................................................................................................................................................. [ ] an undiagnosed physical or mental disorder whose symptoms are: ......................................................................................................................................................................................................................................................................... I understand that a person with dysphasia or other communications disorders who is mentally competent and able to communicate shall not be considered incapable of giving informed consent by law and this respondent is not such a person to the best of my knowledge. The medical standard of care calls for the following testing, observation or treatment of the above-described physical or mental disorder within the next [ ] twenty-four (24) hours (§37.2-1104) [ ] twelve (12) hours (§ 53.1-40.1(F)) to prevent death, disability or a serious irreversible condition: (Check and complete if applicable) [ ] the respondent does not desire testing, observation or treatment because of the following religious practices: ......................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................ [ ] family member objections are: ................................................................................................................................................................................................................................................................ ........................................................................ DATE AND TIME _______________________________________________________________ PHYSICIAN'S SIGNATURE Oral petition by the above-named physician, who agreed with this transcription when it was read back to him or her. ........................................................................ DATE AND TIME _______________________________________________________________ SIGNATURE FORM DC-489 (MASTER) 1/06 American LegalNet, Inc. www.USCourtForms.com

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