Medical Information Affidavit
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Medical Information Affidavit Form. This is a Hawaii form and can be use in Family Court Statewide.
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Tags: Medical Information Affidavit, Hawaii Statewide, Family Court
Please affix this form to a manila envelope containing medical information. Do not file these documents. Submit the
unsealed envelope when filing your petition for adoption with Legal Documents or to the Family Court Adopiton Clerk if
presented after the petition has been filed.
IN THE FAMILY COURT OF THE _________CIRCUIT
STATE OF HAWAII
In the Matter of Adoption of
)
)
A [ ]MALE [ ]FEMALE CHILD,
Born on:
A [ ]MALE [ ]FEMALE CHILD,
Born on:
A [ ]MALE [ ]FEMALE CHILD,
Born on:
A [ ]MALE [ ]FEMALE CHILD,
Born on:
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by
[ ]the legal spouse of [ ]and
FC-A NO.
[ ]the child(ren)'s legal parent
)
[ ]husband and wife [ ]an unmarried person )
)
Petitioner(s). )
)
Included in this envelope are the following forms:
[ ]
Medicial Information Form for:
[ ]
[ ]
[ ]
Medical Record Release of the above data for:
[ ]
[ ]
[ ]
Natural Mother
Natural Father
Natural Mother
Natural Father
Mother’s medical records of the child(ren)’s birth and mother’s release of these
records
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