Indiana Guardianship Form E-13 - Physician'S Report (Page 3 of 3) in pdf

Indiana Guardianship Form E-13 - Physician'S Report Page 3

I affirm under the penalties for perjury that the foregoing representations are true.

Dated this _____ day of _______________________ , 20 _____ .

Signed:

_______________________________

Printed Name: _______________________________

Address:

_______________________________

Telephone:

_______________________________

If the description of the Patient’s mental, physical and educational condition, adaptive behavior or social

skills is based on evaluations by other professional, pleas provide the names and addresses of all

professionals who are able to provide additional evaluations. Evaluations on which the report is based

should have been performed within three (3) months of the date of the filing of the Petition.

Name and addresses of the other persons who performed evaluations upon which this Report is based;

Name (s):

_________________________________________________________________________

Address (s):

_________________________________________________________________________

Telephone (s): _________________________________________________________________________

IC 29-1-1-19

Indiana Guardianship Form E-13 - Physician'S Report Page 3