MEDICAL EMERGENCY CUSTODY PETITION Commonwealth of Virginia VA. CODE § 37.2-1103 Case No. ........................................................................ ............................................................................................................................................................................ CITY OR COUNTY [ ] General District Court [ ] Circuit Court ......................................................................................................................................................................................................................................................................... NAME OF RESPONDENT ADDRESS OF RESPONDENT I, .............................................................................................................................................................. NAME OF PHYSICIAN , a licensed physician, state that: I have communicated with the emergency medical services personnel on the scene and attempted to communicate with the respondent to obtain information and medical data concerning the cause of the respondent's incapacity. I attempted to obtain consent of the respondent for treatment of the following mental or physical disorder ......................................................................................................................................................................................................................................................................... and have failed to obtain such consent. The respondent is within the judge's or magistrate's jurisdiction at ......................................................................................................................................................................................................................................................................... NAME AND ADDRESS OF LOCATION OF RESPONDENT In my opinion, the respondent is incapable of making an informed decision on treatment of the above-described mental or physical disorder, has refused transport to obtain treatment, has indicated an intention to resist transport, and is unlikely to become capable of making an informed decision on obtaining necessary treatment within the time required for such decision because of: [ ] the following physical injury or illness: ................................................................................................................................................................................ [ ] an undiagnosed physical injury or illness whose symptoms are: ......................................................................................................................................................................................................................................................................... I understand that a person with dysphasia or other communication disorder who is mentally competent and able to communicate shall not be considered incapable of giving informed consent by law and the respondent is not such a person to the best of my knowledge. The medical standard of care indicates that the following testing, observation or treatment of the above-described disorder should be provided to prevent imminent and irreversible harm: ......................................................................................................................................................................................................................................................................... (Check and complete if applicable) [ ] The respondent does not desire testing, observation or treatment because of the following religious beliefs or basic values: ......................................................................................................................................................................................................................................................................... ................................................................................. DATE AND TIME ___________________________________________________________________ PHYSICIAN'S SIGNATURE [ ] Oral petition by above-named physician, who agreed with this transcription when it was read back to him. ................................................................................. DATE AND TIME ___________________________________________________________________ SIGNATURE OF MAGISTRATE American LegalNet, Inc. www.FormsWorkFlow.com FORM DC-491 MASTER 11/10