Release Of Medical Information {VN132}

VN132 Superior Court of California County of Ventura Family Court Services PO BOX 6489 800 SOUTH VICTORIA AVENUE ROOM 307 VENTURA CA 93009 (805) 289-8735 FAX (805) 477-5865 RELEASE OF MEDICAL INFORMATION I _______________________________________ , legal guardian of _______________________________________ Guardian's Name Child's Name grant permission for ______________________________________________________________________________ Doctor and Clinic Name _______________________________________________ Clinic Address ______________________________________ Clinic Telephone Number to release information about the health and well-being of the ward to the Ventura County Superior Court. ____________________________ Date ____________________________________________ Guardian's Signature ____________________________________________ Guardian's Printed Name THE SECTION BELOW WILL BE COMPLETED BY THE HEALTH CARE REPRESENTATIVE ---------------------------------------------------------------------------------------MEDICAL INFORMATION Case Number: __________________________________ Medical Number: _______________________________ Child's Name: __________________________________ Guardian: _____________________________________ Date of Birth: _______________________________ When was your last appointment with the child? _________________________________________________________________________________________________ How oftern have you seen the child in the past year? _________________________________________________________________________________________________ Does the child have any conditions which require regular treatment? _________________________________________________________________________________________________ _________________________________________________________________________________________________ Is the child current on the recommended vaccinations? ____________________________________________________ If not, which are overdue? __________________________________________________________________________ Mandatory Form VN132 (Rev. 01/02) RELEASE OF MEDICAL INFORMATION Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com VN132 MEDICAL INFORMATION How would you rate the child's general health? _________________________________________________________ _______________________________________________________________________________________________ Does the child have any special needs? _______________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Does the child have any special problems? ____________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Do you have any observations or additional comments regarding the caretaker's (parent, grandparent, or relative) history of responsiveness to the medical needs of the child(ren)? _________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Additional Remarks: ______________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _____________________________________________ Name of person filling out form _________________________________________ Title of person filling out form _____________________________________________ Signature of person filling out form _________________________________________ Date of signature Mandatory Form VN132 (Rev. 01/02) RELEASE OF MEDICAL INFORMATION Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com