Physicians Declaration printable pdf download

Physicians Declaration

INSTRUCTIONS

2 OF 4 DOCUMENTS NEEDED WHEN REQUESTING REAPPOINTMENT

Letters on the left hand side of these instructions match numbers on the form

REMEMBER USE BLACK INK PEN ONLY

PHYSICIAN’S DECLARATION

CONSERVATOR:

PLEASE COMPLETE THE TOP OF THE FORM:

A: Lefthand side: Fill in the Conservatee’s (patient’s) name. If residing in a facility, include

the facility name, address, and telephone #

B:. Righthand side: Fill in the Court Case #, Conservatee’s Age, Sex, and Birthdate.

STOP -- The remainder of this form must be completed by the conservatee’s

psychiatrist or a licensed psychologist who has practiced for at least five (5) years. The

form will not be accepted by the court if completed by a general practitioner / medical

doctor / social worker or nurse. The Court will accept one doctor’s signature, if you are

unable to get a second doctor’s signature.

ONCE THE ORIGINAL FORM IS COMPLETED AND SIGNED BY THE DOCTOR(S) YOU

MUST FILE THE FORM WITH THE COURT.

If you have questions, please call the Mental Health Clerk’s Office at (323) 226-2917 or 2918.

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Physicians Declaration