Receipt For Medical And Genetic Information
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Receipt For Medical And Genetic Information Form. This is a Wisconsin form and can be use in Washington Local County.
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Tags: Receipt For Medical And Genetic Information, AD-3001, Wisconsin Local County, Washington
STATE OF WISCONSIN, CIRCUIT COURT, WASHINGTON COUNTY, PROBATE
IN THE MATTER OF THE ADOPTION OF:
RECEIPT FOR MEDICAL AND
GENETIC INFORMATION
___________________________________
Case No: ________________
I acknowledge that I have been provided with a copy of the above-named child’s medical
and/or genetic records as provided by Wisconsin Statutes 48.93(1g), 48.425(1)(am), 48.422(9) or
48.425(2).
Signature of Adoptive Parent
Name Printed or Typed
Distribution:
1. Original - Court
Date
AD-3001 (Local) Washington County – Receipt for Medical and Genetic Information (Rev. 3/29/05)
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