IN THE DISTRICT COURT OF ___________ COUNTY, ____________ STATE
______________________ As the Mother,
And next friend of _____________, A minor,
District Court Civil Action Number:
______________________ DV ____________
AFFIDAVIT OF HEALTHCARE TREATMENT
I ________________________ M.D. do hereby certify under oath the following: On or about ____________ through __________________, the plaintiff, ______________________, was under my care and treatment for the following injuries and/or condition: ____________________________ ___________________________________________________________.
By neurosurgeon exam of __/__ /____ , it was determined that the patient had no problems and the symptoms had subsided, however, the problem was real.
The charges for my medical care were ____________________, and in my opinion, the medical services were necessary and the charges for said services were fair and reasonable.
Furthermore, based upon the medical history provided by _____________, the medical records and my education, professional training and experience, it is my opinion to a reasonable degree of medical certainty that the injury and/or condition that necessitated the above medical care was caused by the accident and/or incident of __________________________.
The attached medical records of ___________________ constitute a true and complete copy of his/her medical records regarding the referenced treatment and are kept in the ordinary course of business.
DONE THIS THE ____ DAY OF ___________, 20 ___.
Sworn and subscribed before me this the __ day of __________, 20____ .
My commission expires:_______
State Specific Affidavit Forms
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