NOTE: This affidavit will be used in a legal proceeding to appoint a guardian for the patient named below. The information it contains must be based on your personal examination of the patient. Thank you for your concern and cooperation. IS THIS AN EMERGENCY GUARDIANSHIP PETITION? If an emergency appointment of guardian is needed, please complete page three (3) of this form in addition to pages 1 and 2. ADD RESS: DATE OF BIRTH: located at: ( name) (Address) (Telephone number) I am duly licensed and accredited in the following areas of medical practice: The history of my involv ement with this patient is the following: Diagnosis: I personally examined this patient on , 20 . The examination lasted approximately (Time) Relevant test s and results: Rev. 2 /2019 American LegalNet, Inc. www.FormsWorkFlow.com Does the patient have difficulty communicating? If so, describe the difficulty in detail, and Based on tests and my examin ation of this patient, it is my professional opinion that she/he: does not have does have a disability that significantly interferes with the ability to make r esponsible decisions regarding health care, food , clothing , shelter, or finances. (Optional) The following documents are attached as supporting information regarding the particulars of the disability : If the patient has a cognitive disability, describe that disability: In my opinion, the patient does have does not have sufficient mental capacity to understand the nature of guardianship in order to consent to th e appointment of a guardian. I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true. Date Signature Printed Name SWORN TO AND SUBSCRIBED before me this day of 20. Notary Public American LegalNet, Inc. www.FormsWorkFlow.com Patient Name: TO BE COMPLETED WHEN REQUESTING AN EMERGENCY GUAR DIANSHIP Nature of the emergency, such as medical, abuse, neglect, exploitation, etc.: If this is a medical emergency provide the diagnosis: Describe the testing or treatment related to the diagnosis that is urgently needed and why it is urgently needed within the next 72 hours: Date Signature Printed Name SWORN TO AND SUBSCRIBED before me this day of 20. Notary Public American LegalNet, Inc. www.FormsWorkFlow.com