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HIV VIRUS ANTIBODY BLOOD TEST CONSENT FOR TESTING
The American College of Obstetrics & Gynecology recommends routine HIV testing for all
pregnant women, regardless of risk factors.
I hereby agree to have a blood test in order to detect whether I have antibodies in my blood to the HIV
virus which causes AIDS.
I understand that if my test result is positive, I should consider myself infectious (able to pass the virus)
to other persons through sexual contact, needle sharing, contact with my blood or body fluids, or
through my blood or organs if I sell or donate blood or organs.
I understand that if my test result is positive and I fail to return for discussion and counseling, you are
required to report my identity to the health department.
I understand that I have the choice of not being tested, or of being tested somewhere else including the
health department where anonymous testing (where no one knows my name) can be done. I
understand that if I am at a high risk for a positive test I should not have anonymous testing done.
I have been informed of the risk and benefits related to this test, as well as the alternatives to this test.
By signing this document I specifically acknowledge that I have read this patient information sheet about
HIV virus testing and have received personal counseling. I have been given all of the information that I
need to make an informed decision to have the HIV testing done. I have had the chance to ask
questions and all of my questions have been answered so that I understand all of the answers.
Name (please print)_________________________________________
_________________________________
____________________
(Signature)
(Date)
_________________________________
____________________
(Witness)
(Date)
If I am pregnant and my test is positive, I give my permission for my infant/child(ren) to be tested.
_________________________________
_____________________
(Signature)
(Date)
_________________________________
______________________
(Witness)
(Date)

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