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Medical Cetificate Form. This is a Ohio form and can be use in Cuyahoga County (Court Of Common Pleas).
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Tags: Medical Cetificate, Ohio County (Court Of Common Pleas), Cuyahoga
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
IN THE COMMON PLEAS COURT
JUVENILE COURT DIVISION
STATE OF OHIO
COUNTY OF CUYAHOGA
:
Calendar No.
:
MEDICAL CERTIFICATE
Plaintiff(s)
-against-
JUDICIAL SUBPOENA
:
IN THE MATTER OF
CASE NUMBER:
BELIEVED TO BE A ( )DEPENDENT ( )NEGLECTED CHILD
:
:
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.a. reputable practicing. physician,
..............
deposes and says that the following statements are true to the best of his/her knowledge and belief:
1)
, a minor child born on
hospital under the care of the undersigned on
.
, was admitted to
THE PEOPLE OF THE STATE OF NEW YORK
TO Said child is now
2)
years of age, and has been diagnosed as follows:
.
GREETINGS:
3) As a result of such diagnosis, the following medical and/or surgical treatment is
immediately necessary in order to preserve said child=s life:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
.
or adjourned date, to testify and give evidence as a witness in this action on the part of the
AFFIANT
Your 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.
STATE OF OHIO
COUNTY OF CUYAHOGA
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
Sworn to before me and subscribed in my presence this
, 20
.
day of
(Attorney must sign above and type name below)
Notary Public/Deputy Clerk
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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