FORM DC-489 MASTER 07/19 MEDICAL EMERGENCY Case No. ............................................................................ TEMPORARY DETENTION PETITION Commonwealth of Virginia VA. CODE 247247 37.2-1104; 53.1-40.1(F); 53.1-133.04(G) [ ] General District Court ..................................................................................................................................... [ ] Circuit Court CITY OR COUNTY ......................................................................................................................................................................................................................................................................... NAME OF RESPONDENT [ ] PRISONER ADDRESS OF RESPONDENT I, ................................................................................................................. , a licensed physician, or in the case of a prisoner sentenced and NAME committed to the Department of Corrections or confined in a local or regional correctional facility, a licensed physician, psychiatrist, or clinical psychologist, state that: I attempted to obtain consent of the above-named respondent for treatment of the following physical or mental condition .................................................................................................................................................................................................................................................. The respondent is within the jurisdiction of the above-named court at ......................................................................................................................................................................................................................................................................... NAME AND ADDRESS OF FACILITY To the best of my knowledge, the respondent is incapable of making an informed decision, or is incapable of communicating such a decision, on treatment of the above-described physical or mental condition because of: [ ] the following physical or mental condition: ............................................................................................................................................................... [ ] an undiagnosed physical or mental condition whose symptoms are: ......................................................................................................................................................................................................................................................................... I understand that a person with dysphasia or other communications disorders who is mentally competent and able to communicate shall not be considered incapable of giving informed consent by law and this respondent is not such a person to the best of my knowledge. The medical standard of care calls for the following testing, observation or treatment: ....................................................................................................................................................................................................................................................... [ ] within the next 24 hours, pursuant to 247 37.2-1104, to prevent death or disability, or to treat an emergency medical condition that requires immediate action to avoid harm, injury or death. [ ] within the next 12 hours, pursuant to 247 53.1-40.1(F) or 247 53.1-133.04(G), to prevent death, disability or a serious irreversible condition. (Check and complete if applicable) [ ] The respondent does not desire testing, observation or treatment because of the following religious practices: ................................................................................................................................................................................................................................................................ [ ] Family member objections are: ................................................................................................................................................................................................................................................................ ........................................................................ DATE AND TIME SIGNATURE OF PETITIONER [ ] Oral petition by the above-named physician, psychiatrist, or clinical psychologist, who agreed with this transcription when it was read back to him or her. ........................................................................ DATE AND TIME SIGNATURE OF JUDICIAL OFFICER American LegalNet, Inc. www.FormsWorkFlow.com