PETITION/INFORMATION FOR EMERGENCY HEALTH OR MEDICAL TREATMENT PC-606 REV. 10/99 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. ] TO: COURT OF PROBATE, IN THE MATTER OF [Name, address, zip code, and telephone number.] DISTRICT NO. DATE OF BIRTH OF ADOPTED PERSON Hereinafter referred to as the adopted person. PETITIONER[Give name, address, zip code, and telephone number.] THE PETITIONER REPRESENTS that he or she is providing health or medical treatment to the above-named adopted person and that in connection with such treatment, certain information is necessary with respect to the genetic parents of said adopted person. The information sought herein has not been solicited by the petitioner from any other court or agency, and no request for such information is now pending in any other court or agency except: WHEREFORE, THE PETITIONER REQUESTS that this Court disclose the following information with respect to the genetic parents of said adopted person: THE PETITIONER FURTHER REQUESTS that if such information is not in the records of this court, then the court order the public or private agency that supervised the adoption of such adopted person to obtain and disclose the information to such petitioner in accordance with C.G.S. §45a-754(d). The representations contained herein are made under the penalties of false statement. Date: ........................................................................................ Petitioner: PETITION/INFORMATION FOR EMERGENCY HEALTH OR MEDICAL TREATMENT PC-606 American LegalNet, Inc. www.FormsWorkFlow.com