PDF Medical Excuse From Jury Duty Based on Serious Health ...

BASED ON SERIOUS HEALTH CONDITION _____ _____ Patient Name Date of Birth Patient Address Scheduled to appear for jury duty on: _____ PATIENTS SHOULD COMPLETE THE ABOVE SECTION, THEN ASK THEIR DOCTOR TO COMPLETE BELOW. ----- Dear Doctor: The patient identified above is scheduled to appear for jury duty on the dates indicated..

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