State of Minnesota 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: ______________________________________________________________________________ ______________________________________________________________________________ I am / am not of the opinion that the person is in need of a guardian or conservator to help in the care and management of the person / estate of the person. I am / am not aware of the existence of a health care directive executed by the 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.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com