State Of Ca Pregnancy Verification – Fill Out and Use This PDF

Record Release Authorization and Pregnancy Verification

Please have your doctor or clinic fill out the appropriate sections and then sign all three copies in the presence of your doctor or clinic. Return one copy to Pact, keep one for your records and leave one for your clinic or doctor. This form allows us to talk to your clinic or doctor about the medical aspects of the pregnancy and/or the medical condition of your child.

Patient’s Name

Doctor’s Name

Address

Telephone

Contact person

Clinic Name

Address

Telephone

Contact person

Hospital Name

Address

Telephone

Contact person

Proof of Pregnancy

Date this form was completed

Expected delivery date

month day year

Authorized Signature (include title)

Prenatal medical record release

I, ______________________________________, hereby authorize the release of any and

all information and/or records relating to my care including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility to Pact: An Adoption Alliance, the adoptive parents, and the adoptive parents’ physician.

Child’s Record Release Authorization

I, ___________________________________________________, being the parent of

name of birth parent

_______________________________________ a minor child born on

name of child as it appears on birth certificate

____________________________,

date and time of birth

do hereby authorize the release of any and all of the records relating to the care of said child, including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility to Pact: An Adoption Alliance, the adoptive parents, and the adoptive parents’ physician.