Free Microsoft Word - SEVEN-~2.DOC - California


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State: California
Category: Court Forms - Local
Author: STyler
Word Count: 162 Words, 1,114 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lasuperiorcourt.org/forms/pdf/MHConservatorship-7PointLetter.pdf

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QUESTIONS THAT MUST BE ANSWERED WHEN REQUESTING EITHER MEDICAL OR ECT CONSENT WHEN A PATIENT IS ON A TEMPORARY OR LPS CONSERVATORSHIP

Conservatee's name QUESTION #1:

Court Number

What is the condition that requires treatment or surgery?

QUESTION #2:

What is the recommended course of treatment?

QUESTION #3:

What is the predictable results if authority to consent to treatment is denied or delayed by the court?

QUESTION #4:

What is the predictable or probable results if the recommended treatment is given?

Rev. 10/05

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QUESTION #5:

Are there any medical alternatives available?

QUESTION #6:

What are the attendant risks involved in the procedure recommended by the Doctor?

QUESTION #7:

What were the reasonable efforts by the physician and/or the facility to obtain informed consent of the Conservatee?

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. This declaration is executed on___________________ At__________________________, California. __________________________________ Signature

Rev. 10/05

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