SUPERIOR COURT OF SACRAMENTO COUNTY OF SACRAMENTO SITTING AS THE JUVENILE COURT In the matter of Case No. A minor Date of Birth: ____________________ ___________________ PHYSICIAN’S DECLARATION RE: PROPOSED SURGERY (Welf. & Inst. Code, § 369) Dept. No. ______________ This Declaration and any attachments must be typed and completed with as much detailed information as possible. You may attach any clinical information which clarifies the treatment plan. In lieu of a form Declaration, a typed letter may be submitted provided it contains all the information requested in this form Declaration. The signed Declaration or letter should be submitted to the Department of Health and Human Services social worker assigned to the minor’s case. The child has been diagnosed with the following condition(s):_____________________________________________ _______________________________________________________________________________________ ________ It is the undersigned physician’s recommendation that _______________________(name of minor) be provided the following treatment/surgery/procedure/operation: _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ 1. The purpose of the treatment/surgery/procedure/operation is as follows: _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ JV-SC9 S:\mo\procedure\dclsurgery.doc 05/15/00 Page 1 of 3 pages 2. The probable degree and duration of any risks of the medical intervention is as follows: _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ 3. The probable degree and duration of any benefit(s) of the medical intervention is as follows: _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ 4. The consequences of not having the treatment/surgery/procedure/operation is the following: _______________________________________________________________________________________ ________ _______________________________________________________________________________________ ________ 5. The reasonable alternatives to the treatment/surgery/procedure/operation, if any, and their risks and benefits are the following: _______________________________________________________________________________________ _______ _______________________________________________________________________________________ _______ 6. If hospitalization is necessary, it is estimated the child will be hospitalized for what duration: _______________________________________________________________________________________ _______ 7. Any other information you would like to provide the court: _______________________________________________________________________________________ ________ Dated: ____________________ _____________________________________________ Physician’s Signature Name: _______________________________________ Phone No:* _________________ JV-SC9 S:\mo\procedure\dclsurgery.doc 05/15/00 Page 2 of 3 pages Address: ____________________________________ In re: _______________________________ Case No. ___________________________ Fax No: ____________________ _____________________________________________ * Please list telephone number where physician can be reached personally and quickly, 24 hours a day. JV-SC9 S:\mo\procedure\dclsurgery.doc 05/15/00 Page 3 of 3 pages In re: _______________________________ Case No. ___________________________