COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.STATE OF OHIOIN THE COMMON PLEAS COURTCOUNTY OF CUYAHOGAJUVENILE COURT DIVISIONJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)JOURNAL ENTRYAUTHORIZATION FOR EMERGENCY MEDICAL AND SURGICAL TREATMENTCASE NUMBER:IN THE MATTER OF:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .This matter came on for consideration before the Honorable, upon the complaint in ()Neglect ( )Dependency filed byand medical certificate signed by, for permission to retain as a patient,, a minor child ofyears of age, andTHE PEOPLE OF THE STATE OF NEW YORK TOauthorizing the performance of all medical and surgical procedures upon said child by the medical staff of said hospital that its doctors deem necessary for the child=s welfare, as contained in the medical certificate.Upon consideration of the complaint and the representations contained in the medical certificate, the Court finds that theinterests and welfare of the child require that action be taken immediately and without notice. Therefore, it is ordered by the Court, pursuant to Ohio Revised Code Section 2151.33 and Rules 13 of the Ohio Rules of Juvenile Procedure, that permission to retain said child as a patient is hereby granted. It is further ordered that this Court consents to and authorizes the performance of all medical and surgical procedures upon said child by the medical staff of said hospital, pending services of summons and hearing.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomJudgeDateYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theFILED WITH THE CLERK AND JOURNALIZED ON.Court in Witness, Honorableday of, 20 County,BYDEPUTY CLERK(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com