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THE STATE OF TEXAS

STATE OF TEXAS §
V. §
§

TO ANY SHERIFF OR ANY CONSTABLE OF THE STATE OF TEXAS

GREETINGS:
YOU ARE HEREBY COMMANDED TO SUMMON

CUSTODIAN OF RECORDS
________________HOSPITAL
(Address)

Duces Tecum - Provide Original and/or legible reproductions of all medical records to include
reports, copies of all films from radiologic imaging studies, to include any and all x-rays, CT
scans MRI scans, radionuclide scans and all other diagnostic procedures. The records shall be
for the time period of ______, 200_ through ______, 200_. Records pertaining
to________________, D.O.B. _____________, before the Honorable ______ Judicial District
Court of ______ County, Texas to be held at the Courthouse in said county, in _________ on the
________ day of_______________, 200___ at _____ o’clock A.M. then and there to testify as
Witness in behalf of the Defendant in a criminal action pending in said Court,
wherein The State of Texas is Plaintiff and
______________is Defendant
and there remain from day to day and from term to term until discharged by due course of law.
In the alternative, the Custodian of Records may notify the office of___________________ that
said medical records are ready for pickup on or before the above-stated date.

SHERIFF OR CONSTABLE to make due return of this Writ, showing how you have executed
the same, INSTANTER, by the _____ day of _____________________, A.D. 200__.
Witness my official signature and seal at ___________, Texas and issued this _____ day of
_______________________, 200__.

(District Clerk)

by ___________________________
Deputy Clerk, District Courts, ___________County, Texas
ACCEPTANCE OF SERVICE - OFFICER’S RETURN

Came to hand the ______ day of ___________________, 200____ at ___________ o’clock


_____.M.
By delivering a copy of this subpoena to the within named witness at the following time and
place to-wit:
Address:____________________________

Mileage:____________________________
_
Not executed as to the witness named in this subpoena for the following reasons:
______________________________________________________________________________
______________________________________________________________________________