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NC DSS-1811 Medical Exam for Adoption Court Report

In a North Carolina adoption, the agency's report to the court includes a physician's certification of the adoptee's examination on this one-page form. It carries the court caption (General Court of Justice, District Court Division, before the Clerk), names the petitioning parents and the adoptee, and records the date of exam and the physician's findings.

Who completes it

A physician (the signature line reads 'M.D.') certifies that they examined the adoptee and writes the report of findings, then signs and dates it. The agency fills in the caption, the special proceeding number and the names of the petitioners and adoptee.

Submitting and payment

How to submit it
Give the completed form to the county director of social services or the licensed child-placing agency, which presents it with Form DSS-1808 to the Clerk of Superior Court.

Good to know

  • The Clerk of Superior Court forwards the medical form with the Decree of Adoption to the Division of Social Services in the state Department of Health and Human Services.
  • The caption uses the name by which the adoptee will be known if the adoption is granted, so check it against the agency's paperwork.
  • A note at the foot of the form explains that one DSS-1811 is filled in by the physician for the agency to present to the court.
  • The current edition is printed 'DSS-1811 (Rev.11/2014)' under Child Welfare Services; the NC DHHS policy library lists it simply as 'Medical Examination'.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Examination as Part of Report to the Court for the Adoption

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Where does the DSS-1811 go after the physician signs it?

To the director of social services or the licensed child-placing agency handling the adoption. The agency presents it with Form DSS-1808, the report to the court, to the Clerk of Superior Court, who forwards it with the Decree of Adoption to the state Division of Social Services.

What does the physician write on DSS-1811?

The form certifies that the physician examined the named adoptee and gives a space to report the findings, followed by the date, the physician's address and signature. There are no checkboxes, so the findings are written as a short narrative.

Is DSS-1811 a court document?

Yes. It carries the caption of the North Carolina General Court of Justice, District Court Division, before the Clerk, with a special proceeding (SP) number. It becomes part of the agency's report to the court in the adoption proceeding.