GC-380 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): TELEPHONE AND FAX NOS.: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO MADGE BRADLEY BLDG., 1409 4TH AVE., SAN DIEGO, CA 92101-3105 NORTH COUNTY BRANCH, 325 S. MELROSE, VISTA, CA 92083-6627 CONSERVATORSHIP OF THE PERSON ESTATE OF (Name): CONSERVATEE CASE NUMBER: PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT requests that 1. Petitioner (name): a. the conservatee be adjudged to lack the capacity to give informed consent for medical treatment or healing by prayer. b. the conservator of the person be granted the exclusive authority to give consent for medical treatment or healing by prayer that the conservator in good faith based on medical advice determines to be necessary. c. the treatment be performed by a licensed medical practitioner a licensed psychologist within the scope of his or an accredited practitioner of a religion that relies on prayer alone for healing. her licensure orders related to dementia treatment or placement as specified in the Attachment Requesting Special Orders Regarding d. Dementia be granted. (Attach form GC-313.) the order dated (specify): made under Probate Code section 1880 e. be revoked be modified as specified in Attachment 1e be modified as follows (specify): f. other orders be granted as specified in Attachment 1f as follows (specify): g. Letters of Conservatorship be reissued to include a statement that conservator has the powers requested in this petition. 2. There is no form of medical treatment for which the proposed conservatee has the capacity to give informed consent. 3. Attached to this petition is a declaration executed by a licensed physician stating that the conservatee lacks the capacity to give informed consent for any form of medical treatment and giving reasons and the factual basis fort his conclusion. (Label as Attachment 3.) 4. Conservatee section 2355(b). is is not an adherent of a religion that relies on prayer alone for healing as defined in Probate Code (Continued on reverse) Form Approved by the Judicial Council of California GC-380 [Rev. January 1, 1998] SUPCT PR-33 (Rev. 1-98) PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT (Probate Conservatorship) Probate Code, § 1880 at seq. 2000 (C) American LegalNet, Inc. CASE NUMBER: CONSERVATORSHIP OF (Name): CONSERVATEE 5. ATTENDANCE AT THE HEARING Conservatee a. will attend the hearing. does does not wish to contest this petition. is able but unwilling to attend the hearing AND b. is unable to attend the hearing because of medical inability. An affidavit or certificate of a licensed medical practitioner or c. an accredited religious practitioner is affixed as Attachment 5c. d. is not the petitioner, is out of state, and will not attend the hearing. has 6. Special notice notice in Attachment 6.) 7. has not been requested. (Specify the names and addresses of persons requesting, special Filed with this petition is a proposed Order Appointing Court Investigator (form GC-330) that specifies the duties to be performed before granting an order relating to medical consent. 8. The names, residence addresses, and relationships of the spouse and all relatives within the second degree of the conservatee so far as known to petitioner are listed below listed in Attachment 8. Relationship and name Residence address a. Spouse: b. 9. Number of pages attached: Date: * (Signature of all petitioners also required (Prob. Code, § 1020).) (SIGNATURE OF ATTORNEY *) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) (SIGNATURE OF PETITIONER) . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (TYPE OR PRINT NAME) GC-380 [Rev. January 1, 1998] SUPCT PR-33 (Rev. 1-98) (SIGNATURE OF PETITIONER) PETITION FOR EXCLUSIVE AUTHORITY TO GIVE CONSENT FOR MEDICAL TREATMENT (Probate Conservatorship) Page two 2000 (C) American LegalNet, Inc.