Application to Authorize Medication Or Medical Procedure {50.4}

Data Save Enabled PC-MI-50.4 (Rev. 3-2005) PROBATE COURT OF FRANKLIN COUNTY, OHIO Robert G. A. BELSKIS, JUDGE LAWRENCEMontgomery, Judge IN THE MATTER OF CASE NO. APPLICATION TO AUTHORIZE Pursuant to R.C. 5122.271 and/or R.C. 2101.24, the undersigned says that he has information to believe or has actual knowledge that is in need of and is physically mentally unable to receive information required to enable him to give fully informed intelligent and knowing consent to the following procedure: As shown in Attachment A, the undersigned further states that said procedures are necessary to protect the general health and well-being of the above named person and asks that the Court authorize the above procedures. The undersigned further states that this Court has jurisdiction to hear this matter pursuant to R.C. 5122.271 and/or R.C. 2101.24. The undersigned further states that there is no guardian available to consent and that he has attached the opinion of the chief medical officer or attending physician and a concurring opinion by a licensed physician. Applicant Concurring Opinion FRANKLIN COUNTY FORM 50.4 - APPLICATION TO AUTHORIZE American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF CASE NO. ATTACHMENT A Information necessary to provide informed consent: 1. Reason for and nature of the proposed treatment, specifically documenting the nature, seriousness, and probable complications of the illness or disorder. (Describe behavior which demonstrates inability to care for oneself or other factual events showing behavior that is dangerous to self or others.) 2. The probable degree and duration of expected improvement of remission with and without the proposed treatment. Give a history of compliance and response to past treatment. American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF CASE NO. 3. Describe the specific treatment regimen, including a specific medication(s) you are seeking authority to implement. 4. The nature, degree, duration, and probability of side effects and/or significant risk. American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF CASE NO. 5. A reasonable alternative treatment and reasons why the proposed treatment is recommended. Applicant (Chief Clinical Officer if Application is for surgery) Date Treating Physician Date Reset Form American LegalNet, Inc. www.FormsWorkFlow.com