Fill and Sign the Consent Medical Dental Form

JV-448 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY ––––– ––––– ––––– TELEPHONE NO.: ––––– FAX NO. (Optional): ––––– E-MAIL ADDRESS (Optional): ––––– ATTORNEY FOR (Name): ––––– SUPERIOR COURT OF CALIFORNIA, COUNTY OF ––––– STREET ADDRESS: ––––– MAILING ADDRESS: ––––– CITY AND ZIP CODE: ––––– BRANCH NAME: ––––– CHILD'S NAME: ––––– ORDER GRANTING AUTHORITY TO CONSENT TO MEDICAL, CASE NUMBER: SURGICAL, AND DENTAL CARE (Welf. & Inst. Code, § 366.27) ––––– 1. The child is a dependent of the court under Welfare and Institutions Code, section 300. 2. The child is placed by order of this court with a relative caretaker (specify name): ––––– 3. The relative caretaker named in item 2 is granted the authority to provide legal consent for the child's medical, surgical, and dental care. The authority granted by this order is the authority that is held by a parent with full legal custody of a child. ––––– Date: ––––– JUDICIAL OFFICER 4. CERTIFICATION I certify that this document is a correct copy of the original on file in my office and that this order has not been revoked, annulled, or set aside and is still in full force and effect. Date: ––––– Clerk, by ––––– , Deputy (SEAL) Page 1 of 1 Form Approved for Optional Use Welfare and Institutions Code, § 366.27 Judicial Council of California JV-448 [New January 1, 2006] ORDER GRANTING AUTHORITY TO CONSENT TO MEDICAL, SURGICAL, AND DENTAL CARE (Welf. & Inst. Code, § 366.27) electronic form ã 2005 WWW.LawCA.co m Law Publishers