Permanent Medical Disqualification Letter

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Physician’s letterhead: The letter must be printed on Medical Professional’s letterhead and must include a signature or it is invalid

Dear Office of Jury Commissioner:
I am a physician treating [Juror Name] for [identify general nature of medical condition-specific diagnosis is not required.]. This medical condition is a permanent medical condition. In my opinion, [Juror Name] will never be able to perform juror service.
Kindly disqualify [Juror Name] permanently from the performance of juror service.

[Physician’s Signature]
[Physician’s Printed Name]

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