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GEORGIA MEDICAL NARRATIVE REPORT FORM
OCGA § 24-3-18
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COMES NOW, Dr., Mr., Mrs., _________________________, who, after having first been duly sworn, deposes and states, under oath as follows:

I am the examining and treating (check one box below or all boxes that are applicable):

for, Mr., Ms., Dr., __________________________(insert Patient's Name Here,)
(_____, check if patient is a minor).

EXHIBIT "A" (MEDICAL REPORTS):

The records attached hereto as Exhibit "A," is/are my medical report(s). These report(s) contain and discuss one or all of the following concerning the above-named patient: the patient's history, my examination of the patient, my diagnosis (including, if applicable, my opinion(s) regarding the etiology of the patients' injury or disease), the treatment prescribed, the patient's prognosis, my interpretation of tests given, including the basis therefor and my interpretation of examinations including the basis therefor.

EXHIBIT "B" (PROFESSIONAL QUALIFICATIONS):

My Statement of Qualifications and/or Resume is attached hereto as Exhibit "B." It contains, or references, my State of Georgia License No., my office address, mailing address and telephone number(s).

Signed and Dated, this the ______ day of ___________, 20___.



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Dr., Mr., Ms. ______________________




Sworn to and subscribed to before
me this _______ day of _________, 20___.


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NOTARY PUBLIC

[SEAL]

This sworn report and notice of intention to introduce must be provided to the adverse party not less than Sixty (60) days prior to trial. Any adverse party so notified may object to the admissibility of any portion of this report, other than on the ground of hearsay, within fifteen (15) days of being provided with this report. OCGA § 24-3-18(a).