Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Petition For Appointment Of A Temporary Medical Consent Guardian For A Proposed Medical Consent Ward Form. This is a Georgia form and can be use in Probate Court Statewide.
Loading PDF...
Tags: Petition For Appointment Of A Temporary Medical Consent Guardian For A Proposed Medical Consent Ward, GPCSF 36, Georgia Statewide, Probate Court
GEORGIA PROBATE COURT
STANDARD FORM
Petition for the Appointment of a Temporary Medical Consent Guardian for a Proposed Medical
Consent Ward
INSTRUCTIONS
I.
Specific Instructions
1.
2.
3.
4.
5.
6.
II.
This form is to be used in cases when, according to the provisions of O.C.G.A. §29-4-18,
a medical procedure is necessary, the proposed ward is unable to consent, and no other
person as provided in O.C.G.A. §31-9-2 is able or willing to make the medical decisions.
The form must be completed so as to set forth facts which will establish probable cause to
believe that the proposed medical consent ward lacks decision-making capacity and is in
need of a temporary medical consent guardian, pursuant to O.C.G.A. §29-4-18, including
but not limited to
a.
that the requested medical decision is necessary and why the decision is
needed without undue delay;
b.
that the ward is unable to make or communicate such medical decision;
c.
the anticipated duration of the temporary medical consent guardianship;
d.
that no other person has the authority and/or willingness to make the
medical decision; and
e.
whether a petition for the appointment of a guardian or conservator has
been filed or will be filed as to this proposed ward.
According to Probate Court Rule 5.6 (A), unless the court specifically assumes
responsibility, it is the responsibility of the moving party to prepare the proper citation
and deliver it properly so that it can be served according to law. The pages labeled
“court” in the footnote are to be completed by the moving party, unless otherwise
directed by the court.
If probable cause is found by the court, a preliminary hearing shall be held 72 hours after
the filing of the petition, notice of which shall be given to the proposed medical consent
ward in accordance with O.C.G.A. §29-4-18(d) and, unless waived by the court, in
accordance with O.C.G.A. §29-4-18(e).
At the preliminary hearing the court may appoint a temporary medical consent guardian,
set an evidentiary hearing to be conducted no later than four (4) days after the
preliminary hearing, or dismiss the petition by issuing a court order. The forms herein
allow the date for any evidentiary hearing to be determined and set in the order setting the
preliminary hearing, but the decision to go forward with the evidentiary hearing would be
made at the time of the preliminary hearing. If the date and time of the evidentiary
hearing was not set until the preliminary hearing, a second notice shall be given to the
proposed medical consent ward and may be given to any interested party according to
O.C.G.A. §29-4-18(e) who had not been served previously with the order setting the
preliminary hearing.
Additional provisions are required to authorize withdrawal of life-sustaining procedures
and must be specifically authorized by the court.
General Instructions:
General instructions applicable to all Georgia probate court standard forms are available
in each probate court.
Effective 7/11
1
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
STATE OF GEORGIA
IN RE:
)
)
________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
COUNTY
ESTATE NO. _______________________
PETITION FOR APPOINTMENT OF
A TEMPORARY MEDICAL CONSENT
GUARDIAN FOR A PROPOSED
MEDICAL CONSENT WARD
TO THE HONORABLE JUDGE OF THE PROBATE COURT:
1.
Petitioner, ______________________________________________________________, is the
(relationship)________________________________________________________ of the proposed ward,
and is domiciled at (address of petitioner)___________________________________________________
County of ________________ , State of __________________, telephone number _________________.
2.
The proposed ward is _____ years of age, was born (date of birth)______________________, is
domiciled at (address) __________________________________________________________________,
_____________County, State of_____________, and is presently located at_______________________,
a (type of facility, if applicable) ___________________________ in ______________________ County
and can be contacted at (telephone number)
_.
(initial if applicable)
__________
It is anticipated that the proposed ward will be moved within the next 3 days to
the following address: ____________________________________________,
telephone number ______________________________ .
3.
The proposed medical consent ward is in need of a temporary medical consent guardian by reason of the
following incapacity: _____________________________________________________________ to the
extent that the proposed medical consent ward lacks sufficient understanding or capacity to make
significant responsible decisions regarding his or her medical treatment or lacks the ability to
communicate such decisions by any means. The facts which support the claim of the need for a
temporary medical consent guardian are as follows:
NOTE: Pursuant to O.C.G.A. §29-4-18, the Court shall dismiss the petition if the petitioner does not
allege sufficient facts to establish that the proposed medical consent ward is in need of a temporary
Effective 7/11
2
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
medical consent guardian as stated above. The petition cannot be granted unless sufficient facts are
presented which support the need for the appointment of a temporary medical consent guardian. While a
physician’s affidavit is permissible, the petitioner MUST specifically allege sufficient facts to support the
granting of this petition.
_____________________________________________________________________________________
_____________________________________________________________________________________
The foreseeable duration of the proposed medical consent ward’s incapacity will be: _________.
4.
The following medical decisions are needed and must be made without undue delay:
(NOTE: set forth the types of treatment and/or medical procedures for which consent is needed and state
why the decision(s) must be made without undue delay, that is, why the procedures for the appointment of
a non-emergency (permanent) guardian are inadequate to meet the needs of the circumstances):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5.
It is in the best interest of the proposed medical consent ward that _____________________ be
appointed as temporary medical consent guardian. Unless the proposed medical consent guardian is the
petitioner, the name, address, and telephone number of the proposed medical consent guardian
is _________________________________________________________________________________.
6.
(initial one.)
______a.
No other person has authority to act in the circumstances, whether under a power of
attorney, trust, or otherwise.
______b.
The following individual(s) with the authority to act under a power of attorney, trust, or
otherwise, are absent or appear(s) unwilling or unable to act: (name, address, and telephone number):
__
__
___________________________________________________________________________
Effective 7/11
3
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
7.
(initial one.)
______ a.
The proposed medical consent ward does have a living will or advanced directive for
health care which is attached hereto and the nominated agents are listed above in 6(b) or
______b.
To the best of the petitioner’s information and belief the proposed medical consent ward
does not have a living will or advanced directive for health care.
8.
List all possible conflicts of interest between the proposed medical consent ward and the
proposed temporary medical consent guardian including but not limited to being an heir of the proposed
ward; or a beneficiary under his/her will, being a co-owner with the proposed ward with rights of
survivorship of real property and other survivorship or beneficiary interest in bank accounts, retirement
accounts, investment accounts, annuities and life insurance policies.
9.
(initial one)
______A petition for permanent guardianship and/or conservatorship was/is being/will be filed
in conjunction with this Petition.
______No petition for permanent guardianship and/or conservatorship has been/will be filed.
10.
Provide names, addresses and telephone numbers for the following persons who have not joined
in the petition or consented to these proceedings. Describe the relationship, if any, of these persons to the
proposed medical consent ward:
(1) the administrator of the hospital or health care facility where the proposed medical consent
ward is located: _______________________________________________________________________
____________________________________________________________________________________,
(2) the primary treating physician or other physicians believed to have provided any medical
opinion or advice about the condition of the proposed medical consent ward relevant to the petition:
_____________________________________________________________________________________
__________________________________________________________________________ __________,
(3) all other persons the petitioner(s) believe(s) may have information concerning the expressed
Effective 7/11
4
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
wishes of the proposed medical consent ward: _______________________________________________
____________________________________________________________________________________.
11.
Additional Data: Where full particulars are lacking, state here the reasons for any such omission.
WHEREFORE, petitioner(s) pray(s):
1.
2.
3.
4.
5.
that service be perfected as required by law;
that the court appoint legal counsel for the proposed medical consent ward;
that the court conduct a preliminary hearing within seventy-two (72) hours after the filing
of this petition;
that, if necessary, the Court order an evidentiary hearing to be conducted not later than 4
days after the preliminary hearing; and
that a temporary medical consent guardian be appointed for the proposed medical consent
ward.
___________________________
Signature of First Petitioner
_____________________________________
Signature of Second Petitioner, if any
___________________________
Printed Name
_____________________________________
Printed Name
___________________________
Address
_____________________________________
Address
___________________________
_____________________________________
___________________________
Telephone Number
_____________________________________
Telephone Number
Signature of Attorney:
____________________________________
Typed/printed name of Attorney:
Address:
____________________________________
____________________________________
Telephone:
_________________ State Bar #__________
Effective 7/11
GPCSF 36 Petitioner
5
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
VERIFICATION
GEORGIA, _____________________ COUNTY
Personally appeared before me the undersigned petitioner(s) who on oath state(s) that the facts set
forth in the foregoing petition are true.
Sworn to and subscribed before
me this _____ day of_________ , 20____.
____________________________________
First Petitioner
___________________________________
NOTARY/CLERK OF PROBATE COURT
My Commission Expires_______________
____________________________________
Printed Name
-----------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before
me this ____ day of ________, 20__
____________________________________
Second Petitioner, if any
_.
__________________________________
NOTARY/CLERK OF PROBATE COURT
My Commission Expires______________
Effective 7/11
____________________________________
Printed Name
6
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
CONSENT TO SERVE AS TEMPORARY MEDICAL CONSENT GUARDIAN
RE:
PETITION FOR THE APPOINTMENT OF A TEMPORARY MEDICAL CONSENT
GUARDIAN _____
_______, A PROPOSED MEDICAL CONSENT WARD.
I, _________________________________________________________, having been nominated
as temporary medical consent guardian of the above-named proposed medical consent ward, do hereby
consent to serve as temporary medical consent guardian, if so appointed, and do specifically agree that I
am
(1) willing and able to become involved in the proposed medical consent ward’s health care
decisions and
(2) willing to exercise reasonable care, diligence, and prudence and to consent in good faith to
medical or surgical treatment or procedures which the proposed medical consent ward would have wanted
had he or she not been incapacitated.
Where the medical consent ward’s preferences are not known, I agree to act in the proposed
medical consent ward’s best interests; however, I understand that I am not authorized to withdraw lifesustaining procedures unless specifically authorized by the court.
_____________________________________ __
Proposed Temporary Medical Consent Guardian
_______________________________________
Printed Name
_______________________________________
Address
_______________________________________
_______________________________________
Telephone Number
Effective 7/11
7
GPCSF 36 Petitioner
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
Petition for the Appointment of a Temporary Medical Consent Guardian for a Proposed Medical
Consent Ward.
NOTICE
THE FOLLOWING PAGES ARE TO BE
COMPLETED BY THE PETITIONER (MOVING
PARTY) UNLESS OTHERWISE DIRECTED BY
THE COURT. SEE PROBATE COURT 5.6 (A).
Effective 7/11
1
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
_________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
ESTATE NUMBER __________________
PETITION FOR APPOINTMENT OF
A TEMPORARY MEDICAL CONSENT
GUARDIAN FOR A MEDICAL
CONSENT WARD
ORDER FOR APPOINTMENT OF COUNSEL, APPOINTMENT OF SPECIAL PROCESS
SERVER AND NOTICE OF HEARING
The above petition having been read and considered, and it appearing that there is probable cause
to believe that the proposed medical consent ward lacks decision-making capacity and is in need of a
medical consent guardian within the meaning of O.C.G.A. §29-4-18.
IT IS HEREBY ORDERED that__________________________________________________ is
hereby appointed special agent to personally serve
, proposed
medical consent ward, with a copy of the petition for appointment of a temporary medical consent
guardian and this Order/Notice.
IT IS FURTHER ORDERED that a preliminary hearing shall be conducted at ____ o’clock
__.m., _______________________________ on which is within seventy-two (72) hours after the filing
of the petition) at:
(initial as applicable)
______ a. the Probate Court of _______________ County, courtroom ___________, at (address)
___________________________________, ____________________, Georgia.
______ b. (address of location other than courthouse), _________________________________,
Georgia.
IT IS FURTHER ORDERED that, if an evidentiary hearing is ordered at the preliminary hearing:
(Initial as applicable)
_____ the time and date for such hearing, to be held within four (4) days after the preliminary
hearing, will be set at the preliminary hearing, notice of which will be given as the court directs.
_____ shall be held at
o’clock,
.m. on ____________________________,
which is within four (4) days after the date of the preliminary hearing, in________ courtroom
,
_______________County Courthouse at (address)___________________________________, Georgia.
IT IS FURTHER ORDERED that the petitioner(s), and the temporary medical consent
Effective 7/11
2
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
guardian(s) to be appointed if different from the petitioner(s), attend the hearing and give testimony under
oath as the Court may direct.
IT IS FURTHER ORDERED that __________________________________________, attorney
at law, telephone number ______________, is hereby appointed to represent the proposed medical
consent ward.
NOTICE TO PROPOSED WARD:
This is to notify you of a proceeding initiated in this court by seeking to appoint a temporary
medical consent guardian for you.
BY THIS ORDER, THE COURT HAS APPOINTED AN ATTORNEY TO REPRESENT YOU
AND HAS SCHEDULED A PRELIMINARY HEARING. YOU AND YOUR ATTORNEY HAVE
THE RIGHT TO ATTEND ANY HEARING HELD ON THIS MATTER.
IF A TEMPORARY MEDICAL CONSENT GUARDIAN IS APPOINTED FOR YOU, YOU
MAY LOSE IMPORTANT RIGHTS TO CONTROL AND MANAGE YOUR PERSON.
_______
IT IS FURTHER ORDERED that additional service of the petition is hereby
waived
_______
IT IS FURTHER ORDERED that the Clerk/Deputy Clerk shall serve by first
class mail copies of the petition and this order to all interested individuals
identified in paragraphs seven (7) or eight (8) of the petition, if any.
_______
IT IS FURTHER ORDERED that the Clerk/Deputy Clerk shall serve by first
class mail the following persons: _____________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
So ordered this ______ day of ____________________, 20___.
_____________________________________
Probate Judge
Effective 7/11
3
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
CERTIFICATE OF MAILING OF ORDER FOR APPOINTMENT OF COUNSEL,
APPOINTMENT OF SPECIAL PROCESS SERVER, AND NOTICE OF HEARING
ESTATE NAME
ESTATE NO.________________
This is to certify that I have this day served the persons named in the above petition, who were
ordered to be served by first-class mail, with a copy of the foregoing petition and order, by placing a copy
of same in an envelope addressed to each and depositing same in the United States Mail, first-class, with
adequate postage thereon.
_____________________
DATE
____________________________________
PROBATE CLERK/DEPUTY CLERK
CERTIFICATE OF MAILING OF ORDER OF DISMISSAL
ESTATE NAME
ESTATE NO. ________________
This is to certify that I have this day served the proposed medical consent ward with a copy of the
petition and order for dismissal by placing a copy of same in an envelope addressed to the proposed ward
and depositing same in the United States Mail, first-class, with adequate postage thereon. I have also
served a copy of the order for dismissal in the same manner upon the persons required in said order to be
so served.
_________________
DATE
Effective 7/11
____________________________________
PROBATE CLERK/DEPUTY CLERK
4
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
_________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
ESTATE NO. ___________________
PETITION FOR APPOINTMENT OF
A TEMPORARY MEDICAL CONSENT
GUARDIAN FOR A PROPOSED
MEDICAL CONSENT WARD
ORDER FOR DISMISSAL
The above and foregoing petition having been read and considered pursuant to O.C.G.A.
§29-4-18, and based on the petition (and prior to the preliminary hearing) (and following a preliminary
hearing) (and following an evidentiary hearing), it appears that there is not probable cause to believe that
the proposed medical consent ward is in need of a temporary medical consent guardian; therefore, it is
hereby.
ORDERED that the petition is dismissed.
IT IS FURTHER ORDERED that a copy of the petition, the affidavit, if any, and this order be
served on the proposed medical consent ward by first-class mail, and a copy of this order be served in the
same manner upon the petitioner or his/her/their attorney.
SO ORDERED this ____ day of _____________, 20___.
_______________________________
Probate Judge
Effective 7/11
5
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
ESTATE NUMBER _________________
PETITION FOR APPOINTMENT OF
A TEMPORARY MEDICAL CONSENT
GUARDIAN FOR A PROPOSED
MEDICAL CONSENT WARD
RETURN OF SHERIFF/SPECIAL AGENT
I have this day served the proposed medical consent ward, _
,
personally with a copy of the petition for appointment of a temporary medical consent guardian and Order
for Appointment of Counsel, Appointment of Special Process Server, and Notice of Hearing.
This ___ day of _____________, 20___.
____________________________________________
Deputy Sheriff __________________ County, Georgia
____________________________________________
Special Agent
____________________________________________
Printed Name
(If return is by special agent:)
Sworn to and subscribed before me, this
___ day of ______________, 20___.
________________________________
Notary Public/Clerk, Probate Court
My commission expires: ____________
Effective 7/11
6
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
_________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
ESTATE NO. ____________________
PETITION FOR APPOINTMENT
OF A MEDICAL CONSENT GUARDIAN
FOR A PROPOSED MEDICAL
CONSENT WARD
ORDER FOR EVIDENTIARY HEARING
A preliminary hearing was held on the above-referenced petition on ______________________,
20___, and after considering the pleadings and the evidence taken at the hearing,
IT IS ORDERED that an evidentiary hearing shall be conducted (in the Probate Court of
______________________ County, ______________________________________ courtroom, (address)
____________________________________________________________________________, Georgia)
(at the following location: ______________________________________________________________)
at ___ o’clock __.m., on ___________(which is not later than four (4) days after the preliminary hearing);
IT IS FURTHER ORDERED that the petitioner(s), and the Temporary Medical Consent
Guardian(s) to be appointed if different from the petitioner(s), attend the hearing and give testimony under
oath as the Court may direct.
IT IS FURTHER ORDERED that a clerk/deputy clerk shall serve by first-class mail a copy of this
Order on all interested parties who were served notice of the preliminary hearing and the following
person(s): ____________________________________________________________________________.
SO ORDERED this ___________ day of _______________________________, 20_____.
__________________________________________________
Probate Judge
Effective 7/11
7
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
CERTIFICATE OF MAILING OF NOTICE OF EVIDENTIARY HEARING
ESTATE NAME
ESTATE NO.________________
This is to certify that I have this day served the persons named in the above petition, who were
ordered to be served by first-class mail, with a copy of the foregoing notice of evidentiary hearing, by
placing a copy of same in an envelope addressed to each and depositing same in the United States Mail,
first-class, with adequate postage thereon.
_______________________
DATE
Effective 7/11
________________________________
PROBATE CLERK/DEPUTY CLERK
8
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
PROBATE COURT OF
COUNTY
STATE OF GEORGIA
IN RE:
)
)
_________________________________,
)
PROPOSED MEDICAL CONSENT WARD )
)
)
ESTATE NO. __________________
PETITION FOR APPOINTMENT
OF A MEDICAL CONSENT GUARDIAN
FOR A PROPOSED MEDICAL
CONSENT WARD
FINAL ORDER
A preliminary hearing was held on the above-referenced petition on ________________________
20___ (and an evidentiary hearing was held on ____________________, 20____). After considering the
pleadings and the evidence taken at the hearing(s), the Court makes the following:
FINDINGS OF FACT
1.
All procedural requirements of O.C.G.A. §29-4-18 have been met.
2.
The above-named proposed medical consent ward is in need of a temporary medical consent
guardian by reason of _____________________________________________________________. Such
need appears to be limited to the following number of days: ______________________. The temporary
medical consent guardian shall have the limited authority to consent, on behalf of the proposed medical
consent ward, to surgical or medical treatment or procedures not prohibited by law that the proposed
medical consent ward would have wanted had he or she not been incapacitated and that is in the best
interest of the proposed medical consent ward, if known by the medical consent guardian. If the
preferences of the medical consent ward are not known to the medical consent guardian, the medical
consent guardian shall act in the best interest of the proposed medical consent ward.
3.
After reasonable inquiry, a person authorized or willing to consent for the proposed medical
consent ward under the provisions of O.C.G.A. §31-9-2 was absent. The petitioner moved the Court to
appoint ______________________________________________ as temporary medical consent guardian,
asserting that he or she should serve because ________________________________________________.
CONCLUSIONS OF LAW
The Court finds that the above-named proposed medical consent ward, hereinafter referred to as
"the ward," is in need of a temporary medical consent guardian because the ward lacks sufficient
understanding or capacity to make significant responsible decisions regarding his or her medical treatment
or the ability to communicate such decisions by any means.
The temporary medical consent guardian is appointed for the sole and limited purposes of
consenting to surgical or medical treatment or procedures on behalf of the ward that are not prohibited by
Effective 7/11
GPCSF 36 Court
9
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
law and that the ward would have wanted had he or she not been incapacitated, if known to the medical
consent guardian, or, if the ward's preferences are not known, that are in the best interest of the ward.
The temporary medical consent guardianship shall terminate on the earliest of:
(1) the Court’s removal of the temporary medical consent guardian;
(2) the effective date of the appointment of a permanent guardian under O.C.G.A. § 29-4-2;
(3) the duration of the current hospitalization of the ward or the duration of a substantially
continuous stay in another health care facility; or
(4) sixty (60) days from the date of appointment of the temporary medical consent guardian.
IT IS THEREFORE ORDERED that ______________________________________________ be,
and hereby is, appointed temporary medical consent guardian of the ward. Letters of temporary medical
consent guardianship shall issue to the temporary medical consent guardian upon his or her taking the
required oath. The appointed temporary medical consent guardian shall have no authority to act on behalf
of the medical consent ward until Letters of Temporary Medical Consent Guardianship have issued.
IT IS FURTHER ORDERED that the temporary medical consent guardian has the sole and limited
authority to consent to surgical or medical treatment or procedures on behalf of the ward that are not
prohibited by law and that the ward would have wanted had he or she not been incapacitated, if known to
the medical consent guardian, or, if the ward's preferences are not known, that are in the best interest of the
ward.
IT IS FURTHER ORDERED that the temporary medical consent guardian (initial one)
_______
is authorized to withdraw life-sustaining procedures;
_______
is not authorized to withdraw life-sustaining procedures, unless hereafter
authorized by the court.
IT IS FURTHER ORDERED that a copy of this Order shall be hand delivered or mailed by first
class mail to the ward, the medical consent ward’s attorney, the medical consent guardian, the
petitioner(s), and his/her/their attorney(s), if any.
IT IS FURTHER ORDERED that the ward’s legal counsel shall make reasonable efforts to
explain to the ward this Order and the ward’s rights under this Order.
SO ORDERED this ____ day of______________, 20___.
_______________________________________
Probate Judge/Hearing Officer exercising the
Jurisdiction of the Probate Court pursuant to
O.C.G.A. §29-4-12(d)(7) and/or §29-5-12(d)(7)
Effective 7/11
10
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
CERTIFICATE OF MAILING OF FINAL ORDER
I have this date mailed (or handed) a copy of the Final Order Appointing Temporary Medical
Consent Guardian to the medical consent ward, his/her attorney (his/her representatives), the medical
consent guardian, the petitioner(s) and petitioner’s attorney(s).
____________________
DATE
Effective 7/11
________________________________
PROBATE CLERK /DEPUTY CLERK
11
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
STATE OF GEORGIA
COUNTY OF______________________
ESTATE NO. __________________
LETTERS OF TEMPORARY MEDICAL CONSENT GUARDIANSHIP
From the Judge of the Probate Court of said County.
TO:
_______________________, Medical Consent Guardian
RE:
Date of Birth ______________
_________________________, Medical Consent Ward
This Court has found that the above-named medical consent ward is in need of a temporary
medical consent guardian for the sole and limited purpose of the medical consent guardian consenting, on
behalf of the medical consent ward, to surgical or medical treatment or procedures that are not prohibited
by law.
This Court has designated you as such guardian, and you have taken your oath.
You have agreed that you are willing and able to become involved in the medical consent ward’s
health care decisions and that you are willing to exercise reasonable care, diligence, and prudence and to
consent in good faith to medical or surgical treatment or procedures which the proposed medical consent
ward would have wanted had he or she not been incapacitated.
Where the proposed medical consent ward’s preferences are not known, you have agreed to act in
the proposed medical consent ward’s best interest.
These letters expire and the temporary medical consent guardianship terminates on the earliest of:
(1)
(2)
(3)
(4)
the Court’s removal of the temporary medical consent guardian;
the effective date of the appointment of a permanent guardian under O.C.G.A. § 29-4-2;
the duration of the current hospitalization of the medical consent ward or the duration of a
substantially continuous stay in another health care facility; or
sixty (60) days from the date these Letters are issued.
The temporary medical consent guardian (is) (is not) authorized to withdraw life-sustaining
procedures.
Given under my hand and official seal, the ___ day of ____________________, 20___.
_______________________________
Probate Judge
NOTE: The following must be signed if the judge does not
sign the original of this document:
Issued by:
_________________________________
PROBATE CLERK /DEPUTY CLERK
Effective 7/11
(Seal)
12
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
GEORGIA PROBATE COURT
STANDARD FORM
STATE OF GEORGIA
COUNTY OF______________________
ESTATE NO. _________________
OATH OF TEMPORARY MEDICAL CONSENT GUARDIAN
Re: Estate of ____________________________
MEDICAL CONSENT WARD
I do solemnly swear (or affirm) that I will well and truly perform the duties required of me as
temporary medical consent guardian of the above-named medical consent ward.
By taking this oath, I specifically agreed that I am:
(1) willing and able to become involved in the proposed medical consent ward’s health care
decisions and
(2) willing to exercise reasonable care, diligence, and prudence and to consent in good faith to
medical or surgical treatment or procedures which the proposed medical consent ward would have wanted
had he or she not been incapacitated.
Where the medical consent ward’s preferences are not known, I agree to act in the proposed
medical consent ward’s best interest.
I understand that I (am) (am not) authorized to withdraw life-sustaining procedures (as per order of
the court).
______________________________________________
TEMPORARY MEDICAL CONSENT GUARDIAN
Sworn to and subscribed before me, this __________ day of _____________________, 20___.
______________________________________________
Clerk of the Probate Court
Effective 7/11
13
GPCSF 36 Court
American LegalNet, Inc.
www.FormsWorkFlow.com
