Please have your doctor or clinic fill out the appropriate sections and then sign all three copies in the presence of your doctor or clinic. Return one copy to Pact, keep one for your records and leave one for your clinic or doctor. This form allows us to talk to your clinic or doctor about the medical aspects of the pregnancy and/or the medical condition of your child.

Patient's Name

Doctor's Name
Address
Telephone
Contact person

Clinic Name
Address
Telephone
Contact person

Hospital Name
Address
Telephone
Contact person

Proof of Pregnancy
Date this form was completed
Pregnancy has been verified     [ ] yes   [ ] no
Expected delivery date       /     /
                                month day year

______________________________________
Authorized Signature (include title)

Prenatal Medical Record Release

I, ______________________________________, hereby authorize the release to Pact, An Adoption Alliance of any and all information and/or records relating to my care including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility.

_______________________________________	____________
Patient's Name	Date

Child's Record Release Authorization

I, (name of birth parent) ___________________________________________________, being the parent of (name of child as it appears on birth certificate) _______________________________________ a minor child born on (date and time of birth) ____________________________, do hereby authorize the release to Pact, An Adoption Alliance of any and all of the records relating to the care of said child, including history, diagnosis, reports, treatments, labs, or x-rays in your possession while a patient at your facility.

_______________________________________	____________
Parent's Name	Date