PHYSICIAN'S CERTIFICATE/ IMMEDIATE TEMPORARY CUSTODY PC-550 NEW 10/83
STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.]
RECORDED(CONFIDENTIAL VOLUME):
COURT OF PROBATE, DISTRICT OF
DISTRICT NO.
IN THE MATTER OF [Name, address, and zip code] Hereinafter referred to as the minor child.
PHYSICIAN [Name, address, zip code, and telephone number]
CONN. MED. LIC. NO.
THE PHYSICIAN NAMED ABOVE CERTIFIES that: the minor child named above is in need of immediate medical or surgical treatment, the delay of which would be lifethreatening; AND the parent, parents, or guardian of the child refuse to consent to such treatment; AND determination of the need for temporary custody cannot await notice of hearing. .......................................................................................... Physician: Date:
PHYSICIAN'S CERTIFICATE/IMMEDIATE TEMPORARY CUSTODY PC-550 RESET