JURY DUTY MEDICAL EXCUSE LETTER

[Practice name]
[Address]
[Phone and email]

Date: [Date you sign the letter]
To: [The jury office, clerk, or sheriff named on the summons]

Re: [Juror's full name]
Date of birth: [Date]
Juror or summons number: [Number on the summons]
Reporting date on the summons: [Date]

REQUEST
[Juror name] is asking to be [excused from jury service, or deferred to a date on or after a given date, or allowed to serve with the accommodation below]. I support this request for the medical reasons below. The court decides.

ASSESSMENT
I assessed [juror name] [in person, by video, or by phone] on [date of the assessment], and have [treated them since a given year, or seen them for this request only].
Reported by the juror: [Symptoms or limits you did not see yourself, or none]

HOW LONG IT WILL LAST
[Permanent or long-term, or temporary: the date you expect them to be able to serve]
Next review: [Date, or not planned]

WHAT STOPS THEM SERVING
[Each limit as function: how long they can sit, getting to court and around the building, hearing, concentration through a full day, how often and how urgently they need a break, treatment on fixed days]

ACCOMMODATION
[Whether set breaks, a seat near the door or a washroom, an assistive listening device or hearing loop, step-free access, or a later date would let them serve, and which; or: none I know of would be enough, and why]

Diagnosis: [Only if the court's form asks and the juror agrees; otherwise delete this line]
Not assessed: [Anything this letter does not cover, or none]

[Your name, credentials]
[License or registration number, and where issued]
[Signature]

To check this letter: [Practice phone or email]