Fillable Medical Affidavit Exemption (Superior Court of Fulton County)

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Medical Affidavit Exemption (Superior Court of Fulton County)

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Medical Affidavit – Exemption
Juror Name (Print Name) ___________________________________________________________
Candidate ID: _______________________________ Service Date: _________________________
Patient _____________________________________________________is being treated by me for
_____________________________________________________. In my medical opinion, this patient is
permanently disabled and should not be considered for jury service.
______________________________________________
Physician’s Signature
______________________________________________
Physician’s Printed Name
______________________________
Physician’s Telephone Number
Upon completion return this affidavit to:
Fulton County Jury Services
185 Central Ave., SW Suite T-7100
Atlanta, GA 30303
Fax: 404-612-2613
Email: info.juryservices@fultoncountyga.gov
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Medical Affidavit Exemption (Superior Court of Fulton County)

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Completed 1 March 2022

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