A T T O R N E Y S

If you are an attorney, please fill out the following form to request an expert medical declaration for detained clients during the COVID-19 pandemic.

Name of Attorney

First Name

Last Name

Organization

Initials of Client

Deadline for Expert Declaration Letter

YYYY

Do you have the client’s consent to share their medical information with our organization?

Yes

Do you currently have the client’s medical records?

Yes

Please provide a summary of the patient’s conditions and main concerns.

Aside from the obvious risk of being detained during the COVID pandemic, are there any other contributing factors that you would like to be addressed in the letter?

By signing and submitting this form, you attest that you have received written or oral consent to share your client’s medical records with our organization.

Please type your full name below.