[ ii ] -7- TE OF NEW YORK COUNTY OF ---------------------------------------------------------------------------x Proceeding for the Appointment of a Standby Guardian for OF PROGRESSIVELY CHRONIC OR FATAL ILLNESS An Infant. ---------------------------------------------------------------------------x File No. I, , am a physician duly licensed to practice medicine in the State of New York. 1. My license number is: 2. My office is located at: 3. [Check appropriate box]: I am the physician who has primary responsibility for the treatment and care of the petitioner, or I am the physician who is acting on behalf of , the physician who has I have performed tests or evaluations of the petitioner. [Set for th the dates performed.] I have reviewed the tests or evaluations performed on petitioner. Petitioner is medically capable, medically incapable, of appearing at the hearing. [If medically incapable of appearing, explain] 7. I am not a party to this proceeding and affirm the foregoing opinion to be true under the penalties of perjury. Dated: Signature of Physician [ i ] American LegalNet, Inc. www.FormsWorkFlow.com