Hearing Date and Time: __________________
Re ______________________________________, Patient
Date Of Birth ___ / ___/ ____ | Social Security # _____________________
Petition to Authorize Medical Treatment For Incapacitated Adult
The undersigned Petitioner alleges:
1. The Patient is located at _________________________________________.
2. The Patient is incapable of making an informed decision regarding medical treatment, or is incapable of communicating such a decision, due to a physical or mental disorder other than dysphasia or other communication disorder.
3.
The Patient requires the following medical treatment which does not consist
of nontherapeutic sterilization, abortion, or psychosurgery; admission
to a mental retardation facility or a psychiatric hospital; administration
of antipsychotic medication or electroconvulsive therapy; or restraint
or transportation of the person except as is necessary to the provision
of treatment for a physical disorder: _____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________.
4. There is no legally authorized person available to consent to the medical treatment; the Patient is unlikely to become capable of making an informed decision or of communicating an informed decision within the time required for decision; the proposed treatment or course of treatment is in the best interest of the patient and not known to be contrary to the person's religious beliefs or basic values unless necessary to prevent death or a serious irreversible condition.
5. Petitioner requests that the Court consent to the treatment described for Patient and permit the same to be provided by [_] Petitioner or [_] ______________________ ____________________________, a licensed health care services provider in the Commonwealth of Virginia.
6. Petitioner
has delivered a completed copy of this Petition to the Patient.
_______________________________, Petitioner Date: ____________________
Print Name: ______________________________
Petitioner Phone: __________________ (Beeper: ___________)
(Complete in quadruplicate)