Attachment No by dfhercbml

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									                                                                                                          Attachment No. 4
                                             MEDICAL CERTIFICATE
                                       For Prospective Adoptive Parent

Family name, first name, middle name: __________________________________________________________
Date and place of birth:_______________________________________________________________________
Place of permanent residence (address): __________________________________________________________
 _________________________________________________________________________________________
 _________________________________________________________________________________________
 _________________________________________________________________________________________

                                          Results of medical examination

Dermatologist (skin
diseases)_____________________________________________________________
                            (diagnosis)                                             (date)
Gynecologist/Proctologist (sexually transmitted diseases) ___________________________________________
 _________________________________________________________________________________________
                                          (diagnosis)                                                  (date)
Psychiatrist (psychological/mental
diseases)__________________________________________________________________________
____ _____________________________________________________________________________________
                                          (diagnosis)                                                  (date)
Phthisiologist(TB specialist) ___________________________________________________________________
 _________________________________________________________________________________________
                                           (diagnosis)                                                 (date)
Physician (General
practitioner)________________________________________________________________________
_____ ____________________________________________________________________________________
                              (diagnosis)                     (date)

Narcologist (drug/alcohol abuse) _______________________________________________________________
                                                (diagnosis)                                            (date)


                                            Blood tests
Wassermann reaction (syphilis test) _____________________________________________________________
_________________________________________________________________________________________
                                                                (date, number, result)


HIV ______________________________________________________________________________________
 _________________________________________________________________________________________
                                                                (date, number, result)


Conclusion ________________________________________________________________________________
 _________________________________________________________________________________________
 _________________________________________________________________________________________

Doctor ____________________________________________________________________________________
                                          (signature)                                              (printed name)

                   Clinic’s or doctor’s
                           Seal                                                              "___" __________ 200_
                      (if available)


Notarization

								
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