SUPERIOR COURT OF SACRAMENTO COUNTY OF SACRAMENTO SITTING AS THE JUVENILE COURT In the matter of A minor Date of Birth: ____________________ Case No. ___________________ REQUEST FOR COURT ORDER AUTHORIZING SURGERY (Welf. & Inst. Code § 369) DEPT. NO._____________________ 1. Requested surgical procedure: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. The parent legal guardian was contacted and informed of the request for surgery: Yes No If yes, his or her response was as follows: _____________________________________ ________________________________________________________________________ ________________________________________________________________________ If no, explain why not: ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. If unable to locate the parent/legal guardian, please detail the efforts made to locate and obtain his or her consent for surgery: _________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. I informed the parent/legal guardian that I intend to seek a court order without a hearing authorizing the request for surgery. Yes No If not, explain why not: ____________________________________________________ Case Name: Case No.: surgerys:\mo\procedure\surgery.doc 05/15/00 Request for Court Order authorizing surgery Page 1 of 2 Dated: ________________________ 5. ________________________________________________________________________ Minor’s current placement: _________________________________________________ ________________________________________________________________________ I have reviewed for completeness and legibility the documentation submitted by the minor’s physician in support of this Request. The original and one copy of the submitted documents are attached: I declare the above to be true under penalty of perjury under the laws of the State of California. Executed on _____________at ___________________, California. Dated: _____________________ ____________________________________ Social Worker’s Signature Name: _____________________________ (please print, stamp, or type) Phone No: __________________________ Dated: _____________________ Approved: __________________________ Name: _____________________________ (please print, stamp, or type) Case Name: Case No.: Page 2 of 2 Request for Court Order Authorizing Surgery Page 2 of 2 Dated: ________________________