Required fields are marked with asterisks (*)

Hemoglobinopathy Carrier Results Request Form

Child's information

Note: carrier results are only available for babies born after November 24, 2006, as that is the date NSO began screening for hemoglobinopathies.

First name

Last name

Date of birth

Sex

Female

Male

Address

City

Postal code

Birth hospital

Health card number

Is this child from a high-risk group? **

Yes

Anyone can be a carrier of a hemoglobinopathy but it is more common in people from Africa, the Mediterranean, Caribbean, Middle East, South East Asia, Western Pacific Region, South America, and Central America.