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Health Care Provider Order Form for Newborn Screening Kits and Pamphlets

Washington State health care providers can now order newborn screening collection kits and 'Newborn Screening Tests and Your Baby' pamphlets online by completing and submitting the form below.  Each kit includes a specimen collection card, optional hearing test card, envelope addressed to the screening program, and newborn screening educational pamphlet in English.  Individual hearing re-screen cards are also available.  You will receive a confirmation email once the order has been processed.  Please call the Newborn Screening Program Office with questions: (206) 418-5410.

SUBMITTER INFORMATION

Contact Name*:   *required field

Contact Phone Number*: *required field

Contact Email for Order Confirmation:

ORDER INFORMATION

Please indicate the number of each of the following you would like to receive.  We will ship up to a three-month supply of newborn screening kits to your facility.

NBS Collection Kits (includes envelope and English pamphlet): (example: 15)

NBS Collection Kits (includes envelope and English pamphlet), with Hearing (Pink) Insert:

Hearing Re-screen Cards (Blue): (envelope and pamphlet not included)

Additional envelopes only:

Additional Pamphlets (click on language for print-out):
English
Spanish
Cambodian	(Available Online Only)
Chinese	(Available Online Only)
Korean	(Available Online Only)
Laotian	(Available Online Only)
Russian	(Available Online Only)
Somali	(Available Online Only)
Vietnamese	(Available Online Only)

DELIVERY INFORMATION

Hospital, Clinic, or Health Care Provider Name*: *required field

Hospital, Clinic, or Health Care Provider ID#: (Example: H0001, C1245, or M0123)

Attention To: (Please enter full name)

Division or Department:

Address 1:  *required field (Please note: UPS will not ship to PO Boxes)

Address 2:

City:  *required field

Zip Code:  *required field

Purchase Order #:

Special Instructions:

DOH Home | Access Washington | Privacy Notice | Disclaimer/Copyright Information

Washington State Department of Health
Newborn Screening Program
1610 NE 150th Street
Shoreline, Washington, 98155

Last Update : 08/21/2009 05:39 PM
Send inquires about DOH and its programs to the Health Consumer Assistance Office
Comments or questions regarding this web site? Send mail to Gary Resler.