Office of Jury Commissioner
560 Harrison Avenue, Suite 600
Boston, Massachusetts 02118
[Juror Badge Number]
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 Printed Name]