Form 3609.ltbi - Consent And Treatment Plan Latent Tuberculosis Infection (Ltbi) printable pdf download

Consent and Treatment Plan

Latent Tuberculosis Infection (LTBI)

I, _________________________________________________, have been advised and counseled by

(Client’s name)

that based on available information, I (may have

________________________________________________

(Public Health Representative/Title)

/ have) latent tuberculosis infection (LTBI). The following has been explained to me:

1. LTBI means I have been infected by the TB germ M. tuberculosis. My immune system has walled off the

germs to keep them dormant (sleeping). I have no symptoms and can not spread the germ to others.

2. I know that without treatment, I can get sick with active TB disease and have symptoms such as cough,

fever, night sweats, weight loss or extreme tiredness. If any of these symptoms appear, I agree to call the

health department at ___________________ immediately.

3. I understand the link between TB and HIV and therefore I agree to be tested for HIV.

4. I agree to follow this treatment plan. I agree to come to the health department for medical evaluations and

pill refills as ordered and to cooperate in my treatment. If I am unable to keep a scheduled appointment, I

will call the health department at once and reschedule another appointment within 7 days.

5. I agree to take my TB medication as ordered for the entire length of treatment. I will notify the health

department if I am unable to take my medication for any reason.

6. The side effects of the medication I am taking have been explained to me. I agree to call the health

department at ___________________ immediately if I develop any of these side effects.

7. I agree to tell the health department if I move or change my phone number. I agree to tell the health

department how to reach me in person and by telephone.

8. My treatment plan has been explained to me and all my questions have been answered. I have a copy of

this plan.

______________________________________

___________________________

(Client’s Signature)

(Date)

______________________________________

___________________________

(Public Health Representative/Title)

(Date)

______________________________________

___________________________

(Witness/Interpreter’s Signature)

(Date)

Affix Patient label or complete:

Name _____________________________________________

Address ___________________________________________

___________________________________________

City, State, Zip ______________________________________

Telephone _________________________________________

Patient ID# _________________________________________

GA DPH TB Unit

Form 3609.LTBI (Rev. 12/2011)

Form 3609.ltbi - Consent And Treatment Plan Latent Tuberculosis Infection (Ltbi)

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