SUPERIOR COURT OF ARIZONA COUNTY
IN THE MATTER OF: ) ) ___________________________, ) a minor ) ) [Use fictitious name if petitioner ) has so requested] ) ) ___________________________________ ) CASE NO. _____________________ PETITION TO AUTHORIZE PHYSICIAN TO PERFORM ABORTION
I hereby request that this Court enter an order authorizing a physician to perform an abortion without the consent of my parent(s) or guardian or conservator, pursuant to A.R.S. ' 362152(B). 1. 2. 3. I am ________ years old and my date of birth is .
I am aware that the Court will appoint an attorney to represent me, at no charge to me, if I so choose. ____ I request that the Court appoint an attorney to represent me in this matter, free of charge; OR ____ I do not request a court-appointed attorney. I have personally chosen to represent myself, and not be represented by an attorney; OR ____ I am represented by an attorney, as follows: Name of attorney Address Telephone number
I believe I am _____ weeks pregnant or my expected due date is _____________. 1
5. 6. 7.
I want to terminate my pregnancy by abortion. ____ I am mature and capable of giving informed consent to the proposed abortion; AND ____ It is in my best interests to have an abortion without the consent of my parent(s), guardian, or conservator.
For the reasons above stated, I respectfully request that this Court authorize a physician to perform an abortion at my request, without the consent of a parent, guardian, or conservator.
__________________________________________ (Petitioner=s signature, using true name OR fictitious name OR initials)