Juror/Patient Name: Juror Number:
Date Juror is to Report for Jury Duty: / /
Healthcare Provider Information:
Name of Healthcare Provider:
Address:
City: State: Zip:
Phone: Fax:
Juror has been a patient of Healthcare Provider since:
Note to Physician/Nurse Practitioner:
When completing this form, please consider: Jurors are not required to stand for other than brief
moments. Juror typically sit in the courtroom for no more than 1-1 ½ hours at a time and are permitted
to stand or reposition themselves as needed for comfort. The court will make ADA accommodations
upon request and take breaks as needed by any juror.
The undersigned states in good faith that the Juror/Patient has a medical condition that prevents the Juror/Patient
from serving on a jury at this time. This medical condition prevents the Juror/Patient from serving due to an
inability to comprehend information due to mental illness, intellectual disability, senility, or other physical or
mental incapacity. The undersigned further states that the medical condition makes in inadvisable for the
Juror/Patient to serve.
Please select only one and state the condition of Juror/Patient on available line:
Temporarily, and Juror/Patient should be able to serve after (please provide date):
Temporarily, but it is unknown at this time as to when the Juror/Patient will be able to serve in the
future.
Permanently, because the following medical condition will never improve during the rest of the
Juror/Patient’s life. (PLEASE EXPLAIN WHY THE CONDITION PREVENTS SERVING ON A JURY.)
Signature of Physician/Nurse Practitioner Printed Name of Physician/Nurse Practitioner
Florida License No: Date:
*This request must be faxed (904-255-2162), hand delivered or mailed to the Clerk before the date the Juror/Patient is to
report for Jury Duty. It is the responsibility of the Juror/Patient to assure this request is received by the jury clerk in a timely
manner. Mail to: Duval County Clerk of Courts, Attn: Jury Services Department, 501 W Adams St, Rm 2401, Jacksonville,
FL 32202
