Galactosemia Newborn Screening Consent Form
Newborn Information
Baby's Name:
Date of Birth:
Time of Birth:
Hospital/Birth Place:
Parent/Guardian Information
Name:
Relationship to Newborn:
Contact Number:
Information About Galactosemia Screening
Consent
I consent to have my newborn screened for Galactosemia.
Parent/Guardian Signature:
Date:
For Staff Use Only
Staff Name:
Date Collected: