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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