Sample Consent Form - Vhha

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Sample Consent Form
Child ID Program
I,
________________________,
_________________________________________________
(P
)
rint name of mother
consent to collection of my child’s blood sample for the purposes of the Child ID Program. The
hospital will provide the blood sample to me after collection. I understand that once the sample is
given to me, the hospital has no further access to and no further responsibility for the sample,
including its storage, analysis or use.
Signatures
________________________________________________________
Mother
________________________________________________________
Facility representative

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