Time of Filing:
(60) days of the f
Fee: The Clerk
attached to the R
Registry, MUST B
will be photocop
Section I - Affirm
State Registrar on
Section II - Med
will probably not
would convey in
For the purpose
siblings. Other f
this section. The
significant. If ad
include the page
the medical con
Guidance for Completing State Form 9966
The original copy of this form shall be filed with the Clerk of Court accompanying the petition, or within sixty
iling of the petition for adoption.
of Court shall collect an Adoption Medical History Fee of twenty dollars ($20) in each proceeding for
e original copy of this form, including additional pages (if applicable), is to be sent to the State Registrar
ecord of Adoption (SF5438). A photocopy of the Medical History Report (Section II) should be given to the
anytime during the proceeding.
ests for copies of this report, or any other information contained in the Indiana Adoption Medical History
E directed to the State Registrar of Vital Records. (I.C. 31-19-18-1)
ce: All items, except the written signature in Section I, must be typed or clearly printed. Because this form
ied and microfilmed, information must be completed in black ink.
ation: When completed, Section I will contain confidential information and is for the use of the court and
ly. Section I will not be photocopied when making a copy of the Medical History.
ical History: When completing the Medical History, please keep in mind that the recipient of this information
be a physician or an attorney. The Medical History should be completed in language that the average person
formation to a family physician.
Medical History check boxes are provided for the conditions listed in Items 1 through 6 i. Medical
ory information may be provided for the birth mo