ALA JV-002 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, ALAMEDA COUNTY STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: OTHER: CASE NUMBER: RECOMMENDATION, CERTIFICATION, AND ORDER FOR MEDICAL, SURGICAL, DENTAL, OR OTHER REMEDIAL CARE 1. I (Name): My telephone number is: declare that I am a duly licensed physician or dentist under the laws of the state. ; my fax number is: 2. I recommend that immunization, medical and dental examination, preventive, therapeutic and remedial medical and dental procedures, and psychiatric or psychological evaluation and treatment be provided to the minor who is the subject of this action as may be deemed necessary or advisable in accordance with sound medical or dental practice. 3. I recommend that the following major OR minor surgical procedure(s) be performed (specify): 4. The minor's current condition that necessitates the treatment is (specify): 5. The following consequences are to be expected if this treatment is not provided (specify): 6. The risks of the treatment are: (specify): Date: _________________________________________________________ PHYSICIAN DENTIST OTHER (specify): 7. The undersigned Child Welfare Worker OR Deputy Probation Officer certifies as follows: a. The parents, guardians, and/or caretakers of the minor are: Mother or partner: Father or partner: Guardian: Caretaker: Form Adopted for Mandatory Use Superior Court of California, County of Alameda ALA JV-002 [Rev. January 1, 2008] RECOMMENDATION, CERTIFICATION, AND ORDER FOR MEDICAL, SURGICAL, DENTAL, OR OTHER REMEDIAL CARE Welfare and Institutions Code, §§ 369 and 739 Local Rule 5.507(c) American LegalNet, Inc. www.FormsWorkflow.com b. The whereabouts of the parent, guardian, or caretaker are unknown and the following efforts have been made to locate them (specify): c. The parent, guardian, or caretaker is incapable of authorizing the treatment for the following reasons (specify): d. The parent, guardian, or caretaker is unwilling to authorize the treatment for the following reasons (specify): e. This matter has been set for a hearing on (specify): f. Notice of the application and hearing, if any, has been given or attempted as follows (attach separate sheet if necessary to describe attempts to provide notice) (specify): e. Parental rights for the minor were terminated on (Specify date): in action (Specify case number): Date: _________________________________________________________ CHILD WELFARE WORKER DEPUTY PROBATION OFFICER OTHER (specify): QIC: PHONE: _______________ _______________ _________________ _________________ _______________ Date: _________________________________________________________ ATTORNEY FOR MINOR 8. The order for medical or dental care and treatment that has been recommended is GRANTED DENIED. 9. It is hereby ordered that the aforementioned physician or dentist is authorized to administer the medical, dental, surgical, or other remedial care for the minor as is described and recommended by the practitioner. Date: _________________________________________________________ (JUDICIAL OFFICER) Form Adopted for Mandatory Use Superior Court of California, County of Alameda ALA JV-002 [Rev. January 1, 2008] RECOMMENDATION, CERTIFICATION, AND ORDER FOR MEDICAL, SURGICAL, DENTAL, OR OTHER REMEDIAL CARE Welfare and Institutions Code, §§ 369 and 739 Local Rule 5.507(c) American LegalNet, Inc. www.FormsWorkflow.com