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By give my consent for the doctor to release the following medical and other pertinent information regarding me/my child to the Division of Children and Family Services. The findings of this report are to verify freedom from any physical/emotional health condition that would affect the welfare of a foster/adopted child placed in my home. Date Name of person being examined Address, City, State, Zip Name of Parent (if person examined is a minor) Signature of Parent (if person examined is a min.
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