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for prospective adoption parent Family name, first name, middle name: _____________________________________________ Date and place of birth: ________________________________________________________ Place of residence (stay) _______________________________________________________ Dermatovenerologist _____________________ ___________________________________ (diagnosis) (date) Psychiatrist ____________________________ ___________________________________ Phthisiologist___________________________ ________________________________ Therapist ______________________________ ___________________________________ Narcologist ____________________________ ____________________________________ Wassermann reaction____________________________________________________________ HIV infection___________________________________________________________________ Final conclusion________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Head of the treatment-and-prophylactic institution __________ ____________________ (signature) (initials, family name) Seal "___" __________ 200_ This is an Appendix 4 of Resolution of the Cabinet Of Ministers Of Ukraine # 1377 - On approval of the Procedure for registration of children who may be adopted, of the persons who wish to adopt a child, as well as for control of the respect for rights of the adopted children. Also you can find form at Embassy site - http://web.usembassy.kiev.ua/files/medform.rtf |