Adoption Doctors Pre-Adoption Consultations

Please submit this form via email directly from our site, so that we may be able to pre-schedule the evaluation with the particular doctor and just wait for the material to arrive. Print out a copy of this form and submit it with the medical records package.

Individuals requesting evaluation *
Address
Home Phone
Fax
Email
Agency Name
Agency Address
Referred By
Child's Name
Child's Gender
Child's Birth Date
Child's Birth Country
Length of time in orphanage
List prior placements and approximate length of time in each facility
Client's relationship to child
How sure are you about adopting this child prior to evaluation?
Please check off the materials that you would like evaluated for your child: *Medical recordPicturesVideo recording
List information you know about this child but is not included in the material provided
List any specific questions that you may have
Consent for Pre-Adoption Evaluation
I hereby consent to the review, evaluation and assessment by the consulting physicians of Adoptiondoctors.com for the evaluation of the medical records of a child currently available for adoption from Country
I have provided the reviewers with the above mentioned material.

We understand that material will be retuned, but the organization will make copies of all documents, medical record, videotapes and pictures.

I understand the limitations of these evaluations, included but not limited to, the following:
    1) inability to interact or examine the child
    2) quality of the translation or authenticity of the medical record itself
    3) the length of video segment provided.
    4) Language barriers.
    5) lighting and technical difficulties on filming
    6) environment in which the child is in
    7) variability of the child's temperament on a particular day.

I understand that the results of the evaluation of the materials we provide constitute only an opinion based on limited information that may or may not be accurate. This evaluation does not constitute a comprehensive medical examination of the child.It is also understood that no formal Physician patient relationship is established

I understand that the impressions from the evaluations that I am requesting will not include a prognosis or long term prediction of the child's future. I understand that this is not a realistic expectation since the physician is not physically able to examine the child.

I understand that the consulting Physicians can not provide a diagnosis of the health or prognosis of the child that I seek to adopt.

I recognize that a formal assessment and medical evaluation can be rendered by the consulting physician only after a actual physical examination, developmental evaluation, laboratory testing as well as psychological and psychomotor testing are performed.

For patients located locally, a formal post adoption evaluation can be arranged with the consulting physician; otherwise it needs to be arranged with your own private pediatrician.
ConsentI give consentI do not give consent
The reviewers will maintain confidentiality of the identity of the individuals/ organizations requesting the evaluations as well as the the identity of the child
Name Mother
Sign
Date
Name Father
Sign
Date
Please send all materials and this completed form
with a check or money order to:

Adoptiondoctors.com
C/O Dr. George Rogu
646 Commack Road
Commack, NY 11725

Please click on the button "Submit Form By Email" to send us a copy of this form directly from our site, so that we may be able to pre-schedule the evaluation with the particular doctor and just wait for the material to arrive by post. Print out a copy of this form and send it with the medical records package.

Please be advised that records received without a completed consent form will not be evaluated until it is received

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