Materials Requested
Please indicate quantity of each material needed.
At-Risk Screening Questionnaire for Infant Hearing Loss Form
Post-Discharge Hearing Screen Form
Providers of Follow-Up Infant Hearing Screening List
Your Baby's Hearing is Important Brochure (English)
Your Baby's Hearing is Important Brochure (Spanish)
Your Baby Needs Another Hearing Test
- PDF
Postage-Paid, Return Mail Envelopes
We will do our best to honor your request. The amount of supplies requested may be decreased based on supply levels on hand.
Hospital Name
Attention
Address
City
Zip Code
Phone Number
example: (501) 000-0000