Critical Congenital Heart Defects (CCHD) Screening Consent
Infant's Name
Date of Birth
Medical Record Number
Information Provided
I have received information about the CCHD screening and have had the opportunity to ask questions.
Consent
I consent to CCHD screening for my infant.
I do NOT consent to CCHD screening for my infant.
Parent/Guardian Name
Signature
Date
Healthcare Provider Name
Signature
Date
Notes