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_

 

S

Notarization