Supplement For Emergency Guardian Of Person {17.1B}

PC-G-17.1B (Rev. 10-2016) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF CASE NO. SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON [R.C. 2111.02] This Supplement must be completed when there is a request for Emergency Guardianship. The following questions must be answered with specificity and item 1.C, page 1 of the Statement of Expert Evaluation , Form 17.1A, must be checked. 1. Does the patient have a durable health care power of attorney: If yes, why is it not being honored: Yes No 2. Injury(ies) which the alleged incompetent is in danger of receiving: 3. What is the risk of the injury(ies) in 2 above: Possible Likely Substantially Certain 4. What are the medical procedures, if any, which would prevent the injury(ies) in 2 above: 5. What decision(s) can a guardian make that will prevent this/these injury(ies): 6. Ability of the alleged incompetent to receive notice and give consent: 7. Additional statements regarding condition, family, support services, etc.: Note: Any above answers any may be supplemented by attachments. Date and Time of Evaluation Licensed Physician Date of Report FRANKLIN COUNTY FORM 17.1B - SUPPLEMENT FOR EMERGENCY GUARDIAN OF PERSON American LegalNet, Inc. www.FormsWorkFlow.com