Form SG-2 - Physician's opinion of progressively chronic or fatal illness
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF ________
________x
Proceeding for the Appointment PHYSICIAN'S OPINION
of a Standby Guardian for OF PROGRESSIVELY
CHRONIC OR FATAL ILLNESS
________
An Infant. File No. ________
________x
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 primary responsibility for the treatment and care of the petitioner, or
[ ] I am a physician who is familiar with the petitioner's medical condition.
4. [Check appropriate box(es) and explain where requested]:
[ ] [i] I have performed tests or evaluations of the petitioner. [Set forth the dates performed.]
[ ] [ii] I have reviewed the tests or evaluation performed on petitioner. [Set forth the dates performed, and the names of the doctors who performed the tests and/or evaluations.]
5. [Check appropriate box]:
Based upon the foregoing tests or evaluations of the petitioner, it is my opinion, with a reasonable degree of medical certainty, that the petitioner
[ ] has a fatal illness
[ ] Has a progressively chronic illness
[ ] may become incapacitated by reason of a chronic and substantial inability, as a result of mental impairment, to understand the nature and consequences of decisions concerning the care of the petitioner's dependent infant and a consequent inability by petitioner to care for said infant.
6. Petitioner is [ ] medically capable, [ ] medically incapable, of appearing at the hearing. [If medically incapable of appearing, explain]
Date: ________
______________
Signature of Physician