
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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How to fill out the AR CFS-404 online
The AR CFS-404, also known as the General Medical Report, is an essential document for providing medical information regarding a person who is applying to care for children. This guide will walk you through the steps to complete the form online efficiently and accurately.
Follow the steps to complete the AR CFS-404 online.
- Click ‘Get Form’ button to access the AR CFS-404 and open it in your preferred online editor.
- Fill in the 'Date' field at the top of the form. This should reflect the current date on which you are completing the report.
- Provide the 'Name of person being examined' and their complete address, including city, state, and zip code.
- If the individual being examined is a minor, include the 'Name of Parent' and ensure to have the 'Signature of Parent' as well.
- Complete the 'PHYSICIAN’S REPORT / MEDICAL HISTORY' section by entering the necessary medical details such as date of birth (DOB), height, weight, and any relevant physical examinations (e.g., scalp and skin, eyes, ears, etc.).
- In the space provided, list any medications that may affect the individual's ability to care for children.
- Indicate any chronic conditions for which treatment has been received in the last six months.
- Detail any major illnesses and surgeries by providing the date and name of the physician for each surgery.
- For children under the care of the individual, check whether their immunizations are up to date and specify any needed immunizations if applicable.
- For adults, respond to the suitability question regarding their ability to care for children and provide explanations where necessary.
- Finally, enter the 'Name of physician,' ensure their 'Signature' and 'Date' are recorded, along with the business address.
- After completing all sections, ensure to save your changes, and download, print, or share the completed form as needed.
Complete your documents online to ensure a smooth process for your application.
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