Triad Family Services

TRIAD FAMILY SERVICES

MEDICAL-DENTAL-PSYCHIATRIC VERIFICATION FORM Date of Visit: ______

Childs Name: DOB: AGE: Foster Parent: Foster Care Social Worker: Height Today: Weight Today:

Provider Name: Address:

Phone: Fax: REASON FOR THE VISIT: If this is the yearly physical- do not use this form- use CHDP form □ Well Baby Visit □ Immunizations □ Illness □ Injury □ General Medical □ Vision Exam □ Hearing Exam □ Family Planning □ Initial Psychiatric □ On-Going □ 6 Month Dental □ Dental Assessment/Medic Medication Exam Treatment ation Monitoring □ Other:

Provider’s Comments- Diagnosis- Findings

Prescribed Treatment- Medication as prescribed- or Testing

Planned follow-up- Return instructions- or Referral

Updated: 10-09-2014 Health Provider Signature

Updated: 10-09-2014