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Release Of Medical Information Form. This is a California form and can be use in Ventura Local County.
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Tags: Release Of Medical Information, VN132, California Local County, Ventura
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