New Blood Lead Testing Certificate

MARYLAND DEPARTMENT OF HEALTH BLOOD LEAD TESTING CERTIFICATE

For a copy of this form in another language, please contact the MDH Environmental Health Helpline at (866) 703-3266.

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CHILD’S NAME:(Required)

Last First MI

SEX:(Required)

Male

Female

BIRTHDATE:(Required)

PARENT/GUARDIAN NAME:(Required)

Test Date (mm/dd/yyyy)

Type of Test (V = venous, C = capillary)

Result (µg/dL)

Comments

Test Date (mm/dd/yyyy)

Type of Test (V = venous, C = capillary)

Result (µg/dL)

Comments

Test Date (mm/dd/yyyy)

Type of Test (V = venous, C = capillary)

Result (µg/dL)

Comments

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Health Care Provider Document(Required)

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