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Medical Authorization Form. This is a Wisconsin form and can be use in Circuit Court Statewide.
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Tags: Medical Authorization, JD-1734, Wisconsin Statewide, Circuit Court
FORM SUMMARY
Name of Form:
Medical Authorization
Form Number:
JD-1734
Statutory Reference:
§§48.373, 938.373, 938.296(4)
Benchbook Reference:
JV 1
Purpose of Form:
Court authorization, with child/juvenile's consent, for medical
treatment
Who Completes It:
Party seeking the court's approval for the medical treatment
Distribution of Form:
Original to court, copy (certified or authenticated) to treatment
facility
Accompanying Forms:
Generally none, although medical reports detailing the condition
and need for treatment may be attached
New Form/Modification:
Modification, last update 4/97.
Modifications:
Added a file/date stamp to upper right corner. Added a statement
on the bottom indicating that the form shall not be modified.
Comments:
This form cannot be used for testing for HIV/STD under chapter
48. Such testing was repealed for ch. 48. It can be used for
chapter 938 cases pursuant to §938.296(4).
About this form:
This form is the product of the Wisconsin Records Management
Committee, a committee of the Director of State Court's Office and
a mandate of the Wisconsin Judicial Conference.
If you have additional information that does not change the
meaning of the form, attach it on a separate page. The form
itself shall not be altered.
Date: 05/31/00
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For Official Use
STATE OF WISCONSIN, CIRCUIT COURT,
COUNTY
Medical
Authorization
IN THE INTEREST OF
Name
Case No.
Date of Birth
THE COURT FINDS:
1. The child/juvenile is within the jurisdiction of this court.
2. Reasonable cause exists for these services.
3. The child/juvenile consents to the medical and/or surgical procedures requested.
The court authorizes the following medical and/or surgical procedures:
BY THE COURT:
Signature of Circuit Court Judge
Name Printed or Typed
Date
Consent of Child/Juvenile
I consent to the medical and/or surgical procedures requested.
Signature of Child/Juvenile/GAL
Name Printed or Typed
Date
JD-1734, 05/00 Medical Authorization
§§48.373, 938.373, 938.296(4), Wisconsin Statutes.
This form shall not be modified. It may be supplemented with additional material.
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