Request For Court Order Authorizing Emergency Or Non-Routine Medical Surgical {JC-E-679}

REQUEST FROM (Name and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 3341 Power Inn Road, William R. Ridgeway Family Relations Courthouse Sacramento, CA 95826 CASE NUMBER: DEPARTMENT: Sitting as the Juvenile Court CHILD'S NAME: REQUEST FOR COURT ORDER AUTHORIZING EMERGENCY OR NON-ROUTINE MEDICAL, SURGICAL, OR DENTAL CARE THIS IS AN: EMERGENCY REQUEST A NON-EMERGENCY REQUEST 1. The following emergency or non-routine medical, surgical, or dental care procedure is requested: a. b. Attached is the Physician's Declaration Re: Medical, Surgical, or Dental Care. Physician refused without court order. 2. The parent legal guardian was contacted and informed of the request for emergency or nonroutine medical, surgical, or dental care: Yes No a. If yes, his or her response was as follows: b. 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 emergency or non-routine medical, surgical, or dental care: 4. The parent/legal guardian was informed that a court order without a hearing authorizing the request for emergency or non-routine medical, surgical, or dental care was being requested. Yes No, if no, explain why: 5. The child's current placement is: 6. The following parties were notified of this request as follows: Attorney for: Name: Date and Time Informed: Child(ren) County Parent Parent Other JC-E-679 Effective 07/01/2016 REQUEST FOR COURT ORDER AUTHORIZING EMERGENCY OR NON-ROUTINE MEDICAL, SURGICAL OR DENTAL CARE American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 Child's Name Case No: 7. Signature of Moving Party: I declare under penalty of perjury under the laws of the State of California that the information in this form is true and correct to my knowledge. Social Worker's Signature Telephone No.: Date Type Name Date Type Name Approved: Supervisor's Signature Telephone No.: JC-E-679 Effective 07/01/16 REQUEST FOR COURT ORDER AUTHORIZING EMERGENCY OR NON-ROUTINE MEDICAL, SURGICAL OR DENTAL CARE American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2