J C - E - 678 Effective 07/01/2016 ORDER AUTHORIZING EMERGENCY OR NON - ROUTINE MEDICAL, SURGICAL OR DENTAL CARE Page 1 of 1 REQUEST FROM (Name and address): TELEPHONE NO.: E - MAIL ADDRESS (Optional): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road, MAILING ADDRESS: William R. Ridgeway Family Relations Courthouse CITY AND ZIP CODE: Sacramento, CA 95826 BRANCH NAME: Sitting as the J uvenile Court CHILD222S NAME: CASE NUMBER: ORDER AUTHORIZING EMERGENCY OR NON - ROUTINE MEDICAL, SURGICAL, OR DENTAL CARE (WIC 247 369) DEPARTMENT: The Court, having considered the record in this matter, including the attached supporting declaration dated on , requesting that emergency or non - routine medical, s urgical, or dental care be performed on the above - named child, and good cause appearing, hereby ORDERS the following: 1. The request for medical, surgical, or dental care as outlined in the supporting declaration dated on , is GRANTED. 2. The request for medical, surgical, or dental care is DENIED. 3. This matter is set for hearing on: Date Time Department (at the Courthouse address noted above) FURTHER ORDERS: The Department of Child, Family and Adult Services shall provide a copy of this Order to the child222s counsel, counsel for parent(s), if any, and any parent in pro per. Date Judicial Officer American LegalNet, Inc. www.FormsWorkFlow.com