Informed Consent and Agreement to HIV Testing
I understand the following information, which I have read or has been read to me:
Blood, or another body fluid or tissue sample, will be tested for human immunodeficiency virus (HIV) infection;
Consent to be tested for HIV, the virus that causes AIDS, should be given FREELY;
Results of this test, like all medical records, are confidential, but confidentiality cannot be guaranteed; and
If positive test results become known, an individual may experience discrimination from family or friends and at school
What a NEGATIVE Result Means:
A negative test means that HIV infection has not been found at the time of the test.
What a POSITIVE Result Means:
A positive HIV test means that a person is infected with HIV and can transmit the virus by having sex, sharing
needles, childbearing (from mother to child), breastfeeding, or donating organs, blood, plasma, tissue, or breast milk.
A positive HIV test DOES NOT mean a diagnosis of AIDS -- other tests are needed.
What Will Happen if the Test Is Positive:
A copy of the Department of Health and Mental Hygiene's publication "Information for HIV Infected Persons" will be
The health department or my doctor will offer advice about services that are available;
Women who are pregnant or may become pregnant will be told of treatment options which may reduce the risk of
transmitting HIV to the unborn child;
Information will be provided on how to keep from transmitting HIV infection;
My name will be reported to the health department for tests that indicate HIV infection. This includes, but is not limited
to: HIV Antibody (Western blot), HIV Viral Load (RNA or DNA quantification), HIV viral sequencing or HIV p24 antigen
My name will be reported to the health department if my doctor finds that I have AIDS;
I will be offered assistance in notifying and referring my partners for services. If I refuse to notify my partners, a doctor
may notify them or have a representative of the local health department do so. If a representative of the local health
department notifies my partners, my name will not be used. Maryland law requires that when a local health
department knows of my partners, it must refer them for care, support, and treatment.
I have been given a chance to have my questions about this test answered.
I hereby agree to be tested for HIV infection.
Print name of individual to be tested in the boxes below:
Signature of Individual to be Tested
(or Authorized Substitute )
Signature of Counselor or Health Care Provider
State of Maryland - DHMH AIDS Administration
Form 4667 (revised 5/2007)