Required fields are marked with asterisks (*)

Permanent Hearing Loss Carrier Results Request Form

Please complete this form to request a child's carrier results from risk factor screening for permanent hearing loss (PHL). Fields marked with a * are mandatory.

For the privacy and protection of this child, this form must be completed by the child's health care provider or the child's mother (the mother is the only guardian known to NSO as her name is sent to us with the newborn screening sample). If another legal guardian is requesting these results, please mail the completed form with proof of guardianship to NSO. Results will be released to the health care provider listed below

Child's information

First name

Last name

Date of birth

Sex

Female

Male

Address

City

Postal code

Phone number

Health card number

Birth hospital

Does this child have permanent hearing loss?

Yes