Download
INFORMED CONSENT FORM – HIV testing
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PATIENT’S NAME
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UID
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Gender
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Age
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WARD
/ BED NO.
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S.
N
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DESCRIPTION
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1.
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I
………………………………………………………………………………..(name of patient), hereby give my consent to
get my blood tested for HIV antibodies. I have been explained the relevance and
significance of this test, through Pre Test Counselling.
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2.
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I
understand that the result of my test will be kept confidential. Only on my
authorization, my test result will be given to another person. I will be
given a post-test counselling by my doctor / trained counsellor.
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3.
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I
understand following information about HIV testing, as was explained to me.
1.
HIV is the
virus believed to cause AIDS. Antibodies are substances made by the body in
response to infection. A positive test for HIV antibodies means a person is
infected with HIV, but does not necessarily mean a person has AIDS.
2.
Despite the use
of the most advanced technology, a small number of “false positive” results
occur, that is, the test is positive but the person is not infected with HIV.
Also, since it takes time to produce antibodies after the virus enters the
body, some infected individuals may not have a positive test for HIV
antibodies (“false negative” results)
3.
If my HIV
antibody test results are known, it may help my doctor decide how best to
treat me for the illnesses associated with HIV infection. It may also help me
to make personal decisions, if I am at risk for HIV infection or for
transmitting HIV to someone else.
4.
If my blood
test is positive and others know the test result, I might be discriminated
against by friends, family, employers, landlords, insurance companies, and
others. Therefore, I should be extremely careful disclosing my test results.
In addition, a positive test result may be recorded in my medical record
maintained at the hospital and the laboratory
5.
The hospital
has strict rules, in accordance to laws, to keep the HIV testing result confidential from
anyone other than me
6.
Hospital will
make every attempt to ensure the confidentiality of my test result. However,
the possibility of unauthorized disclosure always exists. This might result
in some form of discrimination. Furthermore, if this test for HIV is positive
or if additional tests indicate that I have AIDS, this information must, by
statute, be reported to the State Health Authority (NACO).
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4.
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I also
understand that
1.
I can refuse to
be tested and my refusal will not affect my future care at the hospital.
2.
If my test is
positive, I can expect a post-test counselling about implication of the test
result
3.
I have also
been explained about the procedure of drawing blood and the minimal risk involved in
this
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Signature and
name of the person giving consent
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Date / Time
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Signature and name of the person
taking consent
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Date / Time
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