Authorization for Lead Screening Clinic

Lead poisoning is a serious health issue that can affect normal growth and developments. Children can be exposed to lead paint, dust, and soil in and around the home. A lead screening can help determine if your child has lead poisoning.

Our records indicate that this screening was not recorded on your child’s medical statement (physical). Head Start requires that every child under the age of 72 months have a Lead Level Screening.

The screening is provided through Promise Early Education Center in collaboration with a local Health Care Provider. The screening requires that few drops of blood be obtained by using a finger prick device.

I do consent to my child receiving a lead level screen at Promise Early Education Center.

Child’s Information:

Child’s Name ______

DOB______Mainecare #______

Confidential

I understand that my records are protected under the federal regulations governing confidentiality and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.

______

Parent(s)/Guardian Print Date Parent(s)/Guardian Signature Date

______

Healthcare Provider’s Signature Date

If I do not consent to a Lead level Screen by Promise Early Education Center, I will be asked to read and sign the refusal form on the back, ______

(Please Initial)

If you would like more information and ask questions about this important screening for your child, please contact the Health Coordinator- Norma Larocque at 207-795-4040 ext.312

Refusal for Promise Early Education Center Lead Screen

I understand the importance of getting my child a blood test and I will make an appointment with my child’s physician to get a blood lead test done.

Yes

No

Lead is a poisonous metal that a body cannot use.

Lead in the body stops good mineral such as iron and calcium from working right.

Some of these effects may be permanent.

I understand that lead poisoning can cause my child to have learning, hearing and behavioral problems.

I understand that lead poisoning can harm my child’ brain, kidneys and organs.

I understand the only way to know if my child has lead poison is by getting a blood test.

I have learned that a child may complain of headaches or a stomachache that has lead poisoning

I have learned that a child may become very irritable and tired that has lead poisoning.

I do not consent to my child getting a lead screen done at Promise Early Education Center.

(Parent/Guardian Signature) Date

269 Bates Street, Lewiston, ME 04240P: (207) 795-4040 F: (207) 795-4044