Free Medical Certificate for the Child - Hawaii

FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I
In the Matter of Adoption of A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: by [ ]the legal spouse of [ ]and [ ]the child(ren)'s legal parent [ ]husband and wife [ ]an unmarried person

MEDICAL CERTIFICATE FOR THE CHILD

CASE NUMBER FC-A NO.

Petitioner(s).

The undersigned, being duly licensed to practice medicine in the State of hereby acknowledge that he/she has examined that said child's physical and mental condition is as follows:

does , and finds

.

Date

Signature of Physician

Printed Name of Physician

Address: Telephone Number:
08/07/01 MEDICAL CERTIFICATE FOR THE CHILD