Consent Form For Hiv Test - Chantilly Family Practice Center printable pdf download

Consent Form For Hiv Test - Chantilly Family Practice Center

CONSENT TO TEST FOR HIV

1. ___________________________________ have been advised by my doctor (s) / have

chosen to have a blood test to detect the presence of antibodies to the Human

Immunodeficiency Virus (HIV), the virus that causes AIDS (Acquired Immunodeficiency

Syndrome). I understand that the blood tests for the virus, which is probable cause of

AIDS, are not 100% accurate, and that these blood tests sometimes produce false

negative or false positive test results. I have been informed that a positive test will

necessitate further testing to confirm the results.

I further understand that the

presence of antibodies means that the person probably has been infected with AIDS

virus, but does not necessary mean that a person will develop AIDS.

2. I have been informed about the nature of the blood test – the expected risk and

benefits and I have also had questions about HIV test answered.

3. I understand that the physician will notify me the results of the HIV test in my physical

presence and explain them to me.

4. I understand that my test results will be recorded in my chart at Chantilly Family

Practice Center (CFPC) and the hospitals the CFPC physicians will be treating me in

the event that I am hospitalized now or in the future.

5. Subject to the foregoing, the CFPC, to the best of its ability, will not disclose results of

these test to others except to the extent required by law or except such disclosure is

need in order to safeguard the well-being of patients and employees at CFPC or

other person at risk. Virginia State law requires that the physician notifies the Virginia

Department of Health if the blood test indicates that an individual has been infected

with the HIV virus (Human Immunodeficiency Virus).

On this basis and with full understanding of my actions, I authorize CFPC, its physician

and anyone authorized by them to perform the blood test for the HIV.

Patient’s signature

Date

Patient’s Representative

Date

Witness

CFPC Physician

Form AR-031

Consent Form For Hiv Test - Chantilly Family Practice Center