Consent Form Hiv Test Page 17

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Statement of Objection to HIV Testing
This section is to be used only for pregnant women who object to HIV testing.
Section 384.31, Florida Statues and Rule 64D-3.042, require that each health care provider and/or midwife
attending a pregnant woman, notify a pregnant woman that she will be tested for HIV, syphilis, Chlamydia,
gonorrhea, and hepatitis B unless she declines one or more of the tests.
I, __________________________________________, have been notified that I will be tested for HIV, syphilis,
(Patient’s name)
chlamydia, gonorrhea, and hepatitis B, and that I have the right to refuse any or all tests.
HIV
syphilis
I decline the following test(s): (please initial)
chlamydia
gonorrhea
hepatitis B
___________________________________________
_______________________
Patient’s signature
Date
___________________________________________
_______________________
Witness
Date
Patient refused to sign.
___________________________________________
_______________________
Witness
Date
Name: ______________________________________
ID No.: _____________________________________
Date of Birth: ________________________________
DH 3161, 01/07
Obsoletes all previous editions
Attachment 3
Which may not be used
Operating Procedure 153-31

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