Sickle Cell Disease Newborn Screening Consent Form

Infant Information

Infant’s Full Name Date of Birth Medical Record Number

Parent / Guardian Information

Parent/Guardian Name Relationship to Infant

Consent

I have been informed about the newborn screening for Sickle Cell Disease. The purpose of this screening, the procedure, and any potential risks or benefits have been explained to me. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I hereby give consent for my newborn to undergo Sickle Cell Disease screening.

For Office Use Only

Date of Screening Staff Name