Certificate Of Examination (Riverside Methodist Hospital) {50.20B}

PC-MI-50.20B (02-2012) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN RE: Case No.: MI- Respondent CERTIFICATE OF EXAMINATION Riverside Methodist Hospital Patient's Name Patient's Address 3535 Olentangy River Rd. Age Sex Race Columbus Date of birth Place of birth City Franklin County OH State 43214 Zip Code The undersigned certifies that he / she is a licensed following are facts relating to the examination of the above named patient. , in the State of Ohio, and that the I further certify that I have, with care and diligence, personally observed and examined the named patient on the of That said patient was examined at examination, I believe said patient is / is not in need of , 20 . day , and as a result of such as requested by for reasons outlined below. REMARKS: Please indicate the condition needing attention and the most desirable method of treatment: Examiner's Signature Printed Name Address m36 FRANKLIN COUNTY FORM 50.20B - CERTIFICATE OF EXAMINATION (RIVERSIDE METHODIST HOSPITAL) American LegalNet, Inc. www.FormsWorkFlow.com