SICKLE CELL FOUNDATION OF GEORGIA, INC. SCREENING CONSENT FORM / FORMULARIO DE CONSENTIMIENTO

Thank you for logging in to this site. We hope that it will provide you a convenient means for requesting screening for Sickle Cell and other hemoglobin variants.

If you are completing this Consent Form for your child, please be careful to enter your child's demographic information (ex. Your child's Name, Date of Birth, etc.; not yours).

IF POSSIBLE, PLEASE BE SURE TO HAVE YOUR HEALTH INSURANCE COVERAGE DOCUMENTS AVAILABLE BEFORE YOU BEGIN.

* * * PLEASE ENTER ENTER ALL REQUESTED INFORMATION USING CAPITAL LETTERS. * * *

Gracias por ingresar a este sitio electrónico. Esperamos que este medio sea de su conveniencia para solicitar la prueba de laboratorio con el fin de detectar células falciformes y otras variantes de hemoglobina.

Si usted está llenando este formulario de consentimiento para su hijo/a, por favor asegúrese de ingresar la información demográfica de su hijo/a (Ejemplo. El nombre de su hijo/a, la fecha de nacimiento, etc. NO LA SUYA)

EN LO PISIBLE, ASEGURESE POR FAVOR DE TENER DISPONIBLE LA INFORMACION DE SU SEGURO DE SALUD ANTES DE COMENZAR

*** POR FAVOR INGRESE TODA LA INFORMACION REQUERIDA UTILIZANDO LETRAS MAYUSCULAS***
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