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 Court Number QUESTION #1: 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 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com 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 Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com