__[Attorney name]__
__[Address]__
__[Telephone number]__
Attorney for __[e.g., Defendant]__, __[name]__
_ _ _ _ _ _ Court, County of _ _ _ _ _ _
__[_ _ _ _ _ _ District]__
_ _ _ _ _ _ _ _ _ _ _ _ _ ) No. _ _ _ _ _ _
Plaintiff(s))
vs. )DECLARATION OF __[NAME]__
) SUPPORTING __[NAME]__'S
_ _ _ _ _ _ _ _ _ _ _ _ _ ) MOTION FOR SUMMARY JUDGMENT OR
Defendant(s))SUMMARY ADJUDICATION OF ISSUES
_________________________ )
Hearing: __[date; time]__
Department: _ _ _ _ _ _
Trial Date: __[if set]__
__[Name]__ declares:
1. I am a licensed, practicing physician specialized in
__[state specialty]__.
2. I have personal knowledge of the facts stated in this
declaration and, if called as a witness, could and would testify
to those facts.
3. Plaintiff, __[name]__, was fully informed regarding the
consequences and complications that could result from the
surgical procedure.
4. Plaintiff verbally expressed his understanding of the
consequences and complications that could result from the
surgical procedure.
5. Plaintiff read, dated, and executed a form entitled
"Consent to Surgery--Binding Waiver of Liability," which included
the following language: "I have discussed with my doctor in
considerable detail the nature, extent, and dangers of the
surgery to be performed, as well as the possible consequences,
complications, and side effects of that surgery, all of which I
fully understand. I still want the surgery. I do NOT want a
second opinion."
6. Plaintiff read, dated, and executed this form after
having been fully informed of the consequences and complications
that could result from the surgical procedure.
7. __[Continue declarant's statements]__.
I declare under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.
Date: _ _ _ _ _ _ [Signature]
________________________
__[Typed name]__
__[Title if relevant]__
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Legal Forms : Set Two