Del. R. Ch. Ct. Form 1
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. PATIENT'S NAME:
ADDRESS:
I, __________________ located at
(provider's name) (address)
________________________ .
(telephone number)
I am licensed to practice in the United States in the following states:
I am board Certified in .
This history of my involvement with this patient is the following:
I personally examined __________________ on ____________, 20 ____ .
(Patient's Name)
The examination lasted approximately .
(time)
I performed or ordered the following tests:
Based on tests and my examination of this patient, it is my professional opinion that s/he
[] does not have a disability that interferes with the ability to make or communicate responsible decisions regarding health care, food, clothing, shelter, or administration of property.
[] does have a disability that interferes with the ability to make or communicate responsible decisions regarding health care, food, clothing, shelter, or administration of property.
The particulars of the disability are as follows:
The patient is unable to perform the following functions:
[] In my opinion, the patient does have sufficient mental capacity to understand the nature of guardianship and can consent to the appointment of a guardian.
[] In my opinion, the patient does not have sufficient mental capacity to understand the nature of guardianship and cannot consent to the appointment of a guardian.
I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this petition are true.
______________________________
Date Provider's Signature
Printed Name
STATE OF DELAWARE :
COUNTY OF __________________ :
SWORN TO AND SUBSCRIBED before me this ________ day of __________________, 20____.
Notary Public
Del. R. Ch. Ct. Form 1