Informed consent for the state-mandated newborn metabolic screening program (heel-stick blood spot), covering the panel of conditions screened, specimen collection, laboratory handling, result communication, and specimen storage/research use policies. Parent/guardian signer.
The Newborn Metabolic Screening Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (parent) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, healthcare, newborn, metabolic screening, genetic screening, heel stick. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Newborn Metabolic Screening Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Hospital / Birth Facility:** ___________ **Attending Provider:** ___________ **Newborn's Name (or "Baby [Surname]" if not yet named):** ___________ **Date of Birth:** ___________ **Time of Birth:** ___________ **Medical Record Number:** ___________ **Parent / Legal Guardian Name:** ___________ **Relationship to Newborn:** ___________ --- ## 1. What Is Newborn Metabolic Screening? Newborn metabolic and genetic screening (commonly called the "heel-stick" or "PKU test") is a public health program that tests a small sample of your baby's blood for a panel of serious but treatable medical conditions. Most babies screened will not have any of the conditions tested. For the small number who do, early detection — often before any symptoms appear — can prevent severe disability, organ damage, or death. **Screening is required by law in the State of ___________.** In most states, parents have the right to decline on religious grounds; discuss this with your provider if applicable. --- ## 2. How the Sample Is Collected A trained healthcare professional will prick the baby's heel with a small lancet, collect a few drops of blood onto a specially treated filter paper card (the "Guthrie card" or dried blood spot card), and send the card to the state public health laboratory for analysis. The procedure is brief. The baby may experience momentary pain, which typically resolves within seconds. **Planned Collection Time:** ___________ *Note: Specimens collected before 24 hours of life may require repeat collection at 7–14 days for certain conditions (e.g., phenylketonuria, congenital hypothyroidism) because early collection can produce false-negative results.*