Newborn Screening Forms

Most commonly used forms

• To receive a copy of your child's newborn screening results, please complete and return CDPH Form 4408, Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF), to NBS@cdph.ca.gov (see below for Spanish version). 
• To receive a copy of your child's newborn screening hemoglobin results, please complete and return CDPH Form 4403, Request for Newborn Screening Hemoglobin Results (PDF), to NBS@cdph.ca.gov.

For families

Fact sheets to help parents decide if they want a baby's blood spots detroyed after newborn screening

• What Happens to My Baby's Newborn Screening Blood Spots? (Fact Sheet, English, PDF) 
• ¿Qué se hace con las muestras de sangre del análisis de mi recién nacido? (Fact Sheet, Spanish, PDF)

Forms to request having a baby's blood spots destroyed after newborn screening

• CDPH 4410 (English): Parent Request to Have Newborn Blood Specimen Card Destroyed ( PDF)
• CDPH 4410 (Spanish): Solicitud Para Los Padres Para Destruir La Tarjeta de Muestra de Sangre del Recién Nacido (PDF)

For more information, visit the NBS Program My Baby's Blood Spots web page.

All forms

• CDPH 4408 (English): Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF) ... 
• CDPH 4408 (Spanish): Consentimiento Para La Divulgación y / o Divulgación de Información Confidencial de GDSP (PDF)
• CDPH 4410 (English): Parent Request to Have Newborn Blood Specimen Card Destroyed ( PDF)
• CDPH 4410 (Spanish): Solicitud Para Los Padres Para Destruir La Tarjeta de Muestra de Sangre del Recién Nacido (PDF)
  
• CDPH 4400 (English): NCAA Student Athlete Request for NBS Results (PDF)
• CDPH 4403 (English): Request for Newborn Screening Hemoglobin Results (PDF)
• CDPH 4407 (English): Consent for Release of Dried Blood Specimen from GDSP (PDF)
• CDPH 4407 (Spanish)Consentimiento Para La Liberación de Muestras de Sangre Seca de GDSP (PDF)

For providers

• CDPH 4406 (English): Newborn Screening Transport Log (PDF)
  
• CDPH 4408 (English): Consent for Disclosure and/or Release of Confidential Information from GDSP (PDF)
  
• CDPH 4408 (Spanish): Consentimiento Para La Divulgación y / o Divulgación de Información Confidencial de GDSP (PDF)
• CDPH 4010 (English): Newborn Screening (NBS) Provider Order Form (PDF)