Hearing Screening Referral Form

NEWBORN HEARING SCREENING REFUSAL

I, ___________________________________, ask that the newborn hearing screening NOT

(Parent or Legal Guardian Name)

be performed on my baby _____________________________________.

(Baby’s Name)

I release ____________________________________, my physician/health care provider

(Birthing Facility Name)

from any fault for disability or injury to my baby that might have been found by hearing

screening. I have read the newborn hearing screening information. I fully understand what I

read. I am responsible for choosing not to have the screening done.

___________________________________________

Print Name of Parent or Legal Guardian

___________________________________________

Signature of Parent or Legal Guardian

_____________________________

Date

___________________________________________

Signature of Witness (Optional)

___________________________________________

Date

DSHS EF05-13790

Revised 12/29/2011

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Parent category: Medical