Pact Record Release Authorization And Pregnancy Verification
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Record Release Authorization and Pregnancy Verification
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)
pact, an adoption alliance
4179 Piedmont Avenue, Suite 101, Oakland, CA 94611
Telephone 510.243.9460
Facsimile 510.243.9970
birth parents 800.750.7590
email
Beth Hall, Director
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