PHYSICIAN'S CERTIFICATE/ IMMEDIATE TEMPORARY CUSTODY PC-550 NEW 10/83 RECORDED(CONFIDENTIAL VOLUME): STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] DISTRICT NO. COURT OF PROBATE, 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 American LegalNet, Inc. www.FormsWorkFlow.com