California > Local County > Ventura > Family Law
Release Of Medical Information VN132 - California
| Release Of Medical Information Form. This is a California form and can be used in Family Law Ventura Local County . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index Superior Court of CaliforniaNo. County of Ventura Calendar No. : Family Court Services : Plaintiff(s) : : : JUDICIAL SUBPOENA (805) 662-6694 (805) 654-2240 PO BOX 6489 800 SOUTH VICTORIA AVENUE-againstROOM 307 VENTURA CA 93009 FAX RELEASE OF MEDICAL INFORMATION Defendant(s) : ...................................................... I, Guardian ,legal guardian of Child's Name Doctor and Clinic Name and THE PEOPLE OF THE STATE OF NEW YORK grant permission for TO Clinic Address Clinic Telephone to release information about the health and well being of the ward to the Ventura Superior Court. GREETINGS: Date: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Guardian's Signature , the Honorable at the Court located at County of in room , on the day of , 20 Guardian's printed name in the , at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the THE SECTION BELOW WILL BE COMPLETED BY THE HEALTH CARE REPRESENTATIVE ---------------------------------------------------------------------MEDICAL INFORMATION Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Medical maximum Case Number whose behalf this subpoena was issued for aNumber: penalty of $50 and all damages sustained as a the party on result of your failure to comply. Child's Name: Date of Birth: Guardian: Court in Witness, Honorable County, , one of the Justices of the day of , 20 When was your last appointment with the child? (Attorney must sign above and type name below) How often have you seen the child in the past year? Attorney(s) for Does the child have any conditions which require regular treatment? Office and P.O. Address Is the child current on recommended vaccinations? If not, which are overdue? Mandatory Form VN132 [Rev. 01/01/02] Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : MEDICAL INFORMATION : How would you rate the child's general health? Plaintiff(s) Index No. Calendar No. : : : : JUDICIAL SUBPOENA -againstDoes the child have any special needs? : Does. the .child . . . . . any. special. problems?. .Defendant(s) . . . . . . . . . . . . . . . have . . . . . . . . . . . . . . . . . . . . . . . . . . . . THE PEOPLE OF THE STATE OF NEW YORK TO Do you have any observations or additional comments regarding the caretaker's (parent, grandparent, or relative) history of responsiveness to the medical needs of the child(ren)? GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Additional remarks Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Name of person filling out form: Title: Signature: Date: Attorney(s) for Office and P.O. Address MEDICAL INFORMATION Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Mandatory Form VN132 [Rev. 01/01/02] Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com
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