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Philippine Newborn Screening Project Consent Form

Here's a sample Consent Form of a Newborn Screening Project in the Philippines:

Consent Form of Newborn Screening Project


TRANSCRIPTION:


Republic of the Philippines
Province of Misamis Occidental
Misamis Occidental Provincial Hospital
Oroquieta City
Telefax (088) 531-1529, Tel. Nos. (088) 531-1042


As the parent/guardian of __(Name of baby)____ I, ___(Name of guardian)___ am consenting to include my baby in the "Newborn Screening Project, Details on Newborn Screening have been explained to me and I am allowing the medical personnel involved in the study to collect blood by heel prick for this purpose.

I understand that the data collected from the study will be strictly confidential.
 
_________________________
Signature over Printed Name
Address: ________________

Tel. No.:  ________________
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