Free STATE OF MINNESOTA - Minnesota

State of Minnesota
Select County County of _____________________

District Court Probate Division Judicial District: _________________ Court File No. ____________________ Case Type: 14, Conservatorship

In Re: Guardianship Conservatorship of ___________________________

Physician's Statement in Support of Guardianship/Conservatorship (and Re: Respondent's Inability to Attend Hearing)

I, _________________________________________, the undersigned licensed physician, state that I am the attending physician of the person named above; that I have been the person's physician since, ______________; and that I examined the person on ___________, 20___, and the results of my examination are stated below: Diagnostic impression and description: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Behavioral evidence to support petition for the appointment of a guardian or conservator: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DIAGNOSIS: ______________________________________________________________________________ ______________________________________________________________________________ PROGNOSIS: ______________________________________________________________________________ ______________________________________________________________________________ am / am not of the opinion that the person is in need of a guardian or I conservator to help in the care and management of the person / estate of the person. am / am not aware of the existence of a health care directive executed by the I person named above, a living will, or any other similar document executed in another state and enforceable under the laws of this state. If you are aware of the existence of any of the above-mentioned documents, please provide additional information: ____________________________________________________ _____________________________________________________________________________. Dated_____________, 20_____ ___________________________________ Signature of Attending Physician Address________________________________________ ________________________________________ ________________________________________

GAC 7-U

State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 1 of 2

PHYSICIAN'S STATEMENT RE: RESPONDENT'S INABILITY TO ATTEND HEARING
If the Person is Physically Unable to Attend the Hearing, Complete the Following: By reason of the medical condition of the person named above as supported by the facts set forth in the above statement, it is my opinion that the person is unable to attend the hearing set for ______________________, 20____, on the petition requesting the appointment of a guardian or conservator for the person named above.

Dated ________________

__________________________________ Signature of Attending Physician

GAC 7-U

State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 2 of 2