Oro Valley, AZ · Pima County
Request for Medical Excuse From Jury Service
A physician, physician assistant, registered nurse practitioner, or acceptable professional caregiver completes this form to request a medical excuse from jury service for a patient.
What this form is
This form requests an excuse from jury service based on a prospective juror’s physical or mental condition. It asks for the patient’s identifying details, restrictions, symptoms, expected ability to serve, and information about the medical professional or caregiver completing it. All questions must be answered legibly; the form states an incomplete application is invalid. Some conditions may warrant postponement rather than an excuse.
Who needs it
A physician, physician assistant, registered nurse practitioner, or court-acceptable professional caregiver completes the form for a patient requesting a medical excuse from jury service.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
No notary is required; the completing professional signs and dates the form and swears or affirms its contents are true and correct under penalty of perjury.
How to submit this form
- 1
Download The Form
Download the medical excuse request form.
- 2
Complete The Patient Details
Enter the patient’s identifying information and answer every question legibly.
- 3
Provide Medical Information
Describe the restrictions and symptoms, how long they have occurred, and when the patient may be able to serve.
- 4
Sign And Submit
The completing professional signs and dates the form, swearing or affirming its contents, then submits it to the city department named on the form.
Frequently asked questions
- Who completes the medical jury excuse request?
- A physician, physician assistant, registered nurse practitioner, or a professional caregiver accepted by the court or jury commissioner completes the form for the patient.
- What information does the form request?
- It asks for patient details, mobility or other restrictions, symptoms and their duration, expected ability to serve, and the completing professional’s contact and credential information.
- Do I need a notary for the medical jury excuse request?
- No. The completing professional signs and dates the form and swears or affirms its contents are true and correct under penalty of perjury.
- How do I submit the medical jury excuse request?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Request for Medical Excuse From Jury Service doesn’t need a notary — but if you have another Oro Valley form that does, a commissioned online notary can help.