Consent Form For HIV Test

The HIV test looks for infection with the AIDS virus.
I understand that if this test shows that I have the HIV virus, I am most probably infected and could spread this to someone else.  I could pass the virus to someone I am having sex with, someone I am sharing a needle with, or to my unborn baby if I am pregnant.  If the test results are negative for the HIV virus, I understand I might still have the virus but that it is too early to tell by the HIV test.

I understand that the information from my test will help me to make important choices.  If I do not have the AIDS virus, the counseling provided will help me know how to keep from gettting it.  If I have the HIV virus, it will help me know how to take care of myself and how to keep from passing the virus to someone else.

Rapid HIV tests results that are positive require a confirmation test (Western Blot) which takes about 10 days to receive.  Negative  tests do not require additional tests.  I understand that I can choose not to receive the results from this test.

I understand that after I sign this form, I cannot sue Dr. Benson for not making sure that I know what this test is all about.  I understand what the HIV test is, what I might gain or lose from it, and the meaning of the test information.  I also understand that I should ask all my questions before the test is done.

I AGREE TO BE TESTED FOR THE HUMAN IMMUNODEFICIENCY VIRUS

Initials  or Signature                                     Date            Assigned Test Number

Witness                                                         Date

PRE TEST QUESTIONNAIRE

CIRCLE  THE CORRECT RESPONSE

TRUE OR FALSE

T             F       A positive Rapid HIV test requires a confirmation Western Blot test. This office does not perform this confirmation test on site.  If the Rapid test is positive the confirmation test will take additional days to receive results.

T             F       We recommend a 90 day period of time after a given exposure as enough  time to determine if one has become  HIV infected from that exposure.  Some authorities suggest as little as 25 days.

T             F       There is a moral and legal obligation to inform all potential sexual and past risk sharing partners if you are infected with the HIV virus.  This is true whether or not risk reduction methods are or were used.

T             F       Unless otherwise discussed this test is being done confidentially and anonymously.

T             F       I understand what I need to do to avoid contracting HIV in the future and if I test positive I understand that there is a lot I can do to keep myself healthy.

Initials or signature                              Date

The person has answered the pre-test questions and concerns have been addressed.

Staff Person                                         Date

Paul Benson, D.O.

1964 W. 11 Mile Road

Berkley, MI 48072

Telephone: (248) 544-9300

Fax (248) 544-1148

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Visit Us on the Web at  www.DoctorBeWell.com