Free jury duty excuse letter template 11
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Jeffrey A. Collins
Senior Vice-President/Area Manager
Varoujan Altebarmakian, MD
Physician-in-Chief
Jose DeAnda
Medical Group Administrator
Kaiser Permanente Fresno Medical Center
7300 North Fresno Street
Fresno, California 93720-2942
(559) 448-4500

Jury Duty Medical Excuse Form

Date:

RE:
Address:

Jury Commissioner,
This is to inform you that the patient listed above has been excused from Jury Duty due to this
medical condition:
_____________________________________________________________________________
_____________________________________________________________________________
__________________________ Could serve at a later date.
__________________________ Should never serve.

__________________________
Signature of Attending Physician