LASC MH 041 Rev. 11/18 Page 1 of 2 For Optional Use SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES Reserved for Clerk222s File Stamp COURTHOUSE ADDRESS: PLAINTIFF/PETITIONER: CONSERVATEE: CONSERVATORSHIP 7 POINT LETTER FOR MEDICAL TREAMENT Case Number: The following questions must be answered when requesting either medical or ECT consent when a patient is on a Temporary or LPS conservatorship: 1. What is the condition that requires treatment or surgery? 2. What is the recommended course of treatment? 3. What is the predictable results if authority to consent to treatment is denied or delayed by the court? American LegalNet, Inc. www.FormsWorkFlow.com LASC MH 041 Rev. 11/18 Page 2 of 2 For Optional Use 4. What is the predictable or probable result if the recommended treatment is given? 5. Are there any medical alternatives available? 6. What are the attendant risks involved in the procedure recommended by the Doctor? 7. What were the reasonable efforts by the physician and/or the facility to obtain informed consent of the Conservatee? I, the undersigned, declare under penalty of perjury and under the laws of the State of California, that the foregoing is true and correct. This declaration is executed on at , California. Print Name Signature American LegalNet, Inc. www.FormsWorkFlow.com