1 Start 2 Complete Please fill out the form below if you would like to request a baby’s risk factor screening results for Permanent Hearing Loss (CMV and genetic risk factors). For the privacy and protection of this child, this form must be completed by the child's parent, guardian, or health care provider. Results will be released to the health care provider you list below. If you are a health care provider and you would like to request additional testing for a child with confirmed or suspected cCMV, or Permanent Hearing Loss, please contact us. Alternative, you could visit our Forms page for further information, including the appropriate requisition. Who is completing this form? Name * Phone Number * Who is completing this form? * I am this child's Health Care Provider I am this child's parent and a legal guardian I am this child's legal guardian (please download the request form above and mail it to NSO with the completed Proof of Guardianship form) Child's Information First Name * Last Name * Date of Birth (DOB) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Sex * Female Male Address * City * Postal Code * Birth Hospital * Health Card Number * Newborn Screen Form Number Mother's Information First Name * Last Name * Date of Birth (DOB) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Health Card Number Same as child's address above Same as baby's address above Address * City * Email Postal Code * Child's Health Care Provider Institution/Practice * First Name * Last Name * Phone * Fax * CPSO / College # Is this where the child gets his/her routine health care? Yes No Unsure Questions? Call NSO : 1-877-NBS-8330 (1-877-627-8330) (613) 738-3222 Website : www.newbornscreening.on.ca Email: newbornscreening@cheo.on.ca
