Ohio Probate Form - Page 2
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1
2[Reverse of Form 26.1]
CASE NO. __________
Affiant further certifies that he/she knows that the following treatment facilities are willing and able to
provide the recommended treatment:
______________________________________________________________________________
Name of Treatment Provider
__________________________________
Telephone Number of Treatment Provider
______________________________________________________________________________
Name of Treatment Provider
__________________________________
Telephone Number of Treatment Provider
______________________________________________________________________________
Name of Treatment Provider
__________________________________
Telephone Number of Treatment Provider
_______________________________________________________
Physician’s Signature
_______________________________________________________
Name and Title of Physician (Please Print)
_______________________________________________________
Telephone Number of Physician
_______________________________________________________
License Number of Physician
Print Form
FORM 26.1 – CERTIFICATE OF PHYSICIAN
Effective Date: July 1, 2016
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