Guthrie Test Consent Form

Patient Information

Name:

Date of Birth:

ID Number:

Parent/Guardian Information

Name:

Relationship:

Contact Number:

Consent

I hereby give consent for the Guthrie test (Newborn Screening) to be performed. I have been informed about the purpose, method, and possible results of the test. I understand that my/my child's information will be kept confidential.

Signature:

Date:

Healthcare Provider Name:

To be filled by the responsible healthcare provider.