<p> TRIAD FAMILY SERVICES</p><p>MEDICAL-DENTAL-PSYCHIATRIC VERIFICATION FORM Date of Visit: ______</p><p>Childs Name: DOB: AGE: Foster Parent: Foster Care Social Worker: Height Today: Weight Today:</p><p>Provider Name: Address:</p><p>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:</p><p>Provider’s Comments- Diagnosis- Findings</p><p>Prescribed Treatment- Medication as prescribed- or Testing</p><p>Planned follow-up- Return instructions- or Referral</p><p>Updated: 10-09-2014 Health Provider Signature</p><p>Updated: 10-09-2014</p>