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Get A Permanent Medical Excusal Form. - Escambia County Clerk

Pam Childers Clerk of the Circuit Court and Comptroller Escambia County Clerk of Courts County Comptroller Clerk of the Board of County Commissioners Recorder Auditor REQUEST FOR PERMANENT MEDICAL EXCUSAL MUST BE COMPLETED AND SIGNED BY A PHYSICIAN OR NURSE PRACTITIONER FOR PERMANENT MEDICAL EXCUSAL Name Juror Number Address Report Date INSTRUCTIONS This completed request form for medical excusal MUST be received five business days prior to your report date in writing or by e-mail. Email completed form to juryduty escambiaclerk. com. To check your status visit http //www. escambiaclerk. com/jury/JurySummonsViewStatus. asp Name/Address/Office Phone/Fax Number of Healthcare Provider The undersigned states in good faith that the Juror/Patient has a medical condition that prevents the Juror/Patient from serving on a jury. F.S. 40. 013 9 Signature of Physician/Nurse Practitioner Printed Name of Physician/Nurse Practitioner Florida License Number Date. Com. To check your status visit http //www. escambiaclerk. com/jury/JurySummonsViewStatus. asp Name/Address/Office Phone/Fax Number of Healthcare Provider The undersigned states in good faith that the Juror/Patient has a medical condition that prevents the Juror/Patient from serving on a jury. The undersigned further states that the medical condition makes it inadvisable for the Juror/Patient to Excuse permanently because the medical condition will not improve and Juror/Patient is permanently incapable of caring for self due to mental illness intellectual disability senility or other physical or mental incapacity.

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