Ventura — Release of Medical Information

Ventura — Release of Medical Information¶

VN132 Superior Court of California County of Ventura Family Court Services

PO BOX 6489 800 SOUTH VICTORIA AVENUE ROOM 307 (805) 289-8735 VENTURA CA 93009 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: __________________________________ Date of Birth: _______________________________

Guardian: _____________________________________

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 RELEASE OF MEDICAL INFORMATION Page 1 of 2VN132 (Rev. 01/02)

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 RELEASE OF MEDICAL INFORMATION Page 2 of 2VN132 (Rev. 01/02)