Free PC-550 - Connecticut


File Size: 73.3 kB
Pages: 1
File Format: PDF
State: Connecticut
Category: Court Forms - State
Word Count: 125 Words, 905 Characters
Page Size: 612 x 765.35 pts
URL

http://www.jud2.ct.gov/webforms/forms/pc-550ar.pdf

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PHYSICIAN'S CERTIFICATE/ IMMEDIATE TEMPORARY CUSTODY PC-550 NEW 10/83

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]

RECORDED(CONFIDENTIAL VOLUME):

COURT OF PROBATE, DISTRICT OF

DISTRICT NO.

IN THE MATTER OF [Name, address, and zip code] Hereinafter referred to as the minor child.

PHYSICIAN [Name, address, zip code, and telephone number]

CONN. MED. LIC. NO.

THE PHYSICIAN NAMED ABOVE CERTIFIES that: the minor child named above is in need of immediate medical or surgical treatment, the delay of which would be lifethreatening; AND the parent, parents, or guardian of the child refuse to consent to such treatment; AND determination of the need for temporary custody cannot await notice of hearing. .......................................................................................... Physician: Date:

PHYSICIAN'S CERTIFICATE/IMMEDIATE TEMPORARY CUSTODY PC-550 RESET