INFORMED CONSENT FORM – HIV testing

PATIENT’S NAME UID

Gender Age WARD /

BED NO.
S. N DESCRIPTION
1.
I ………………………………………………………………………………..(name of patient), hereby give my
consent to get my blood tested for HIV antibodies. I have been explained the relevance and significance of
this test, through Pre Test Counselling).

2. I understand that the result of my test will be kept confidential. Only on my authorization, my test result will be
given to another person. I will be given a post-test counselling by my doctor / trained counsellors.

3. I understand following information about HIV testing, as was explained to me.

1. HIV is the virus believed to cause AIDS. Antibodies are substances made by the body in
response to infection. A positive test for HIV antibodies means a person is infected
with HIV, but does not necessarily mean a person has AIDS
2. Despite the use of the most advanced technology, a small number of “false positive”
results occur, that is, the test is positive but the person is not infected with HIV. Also,
since it takes time to produce antibodies after the virus enters the body, some infected
individuals may not have a positive test for HIV antibodies (“false negative” results)
3. If my HIV antibody test results are known, it may help my doctor decide how best to
treat me for the illnesses associated with HIV infection. It may also help me to make
personal decisions, if I am at risk for HIV infection or for transmitting HIV to someone
else.
4. If my blood test is positive and others know the test result, I might be discriminated
against by friends, family, employers, landlords, insurance companies, and others.
Therefore, I should be extremely careful disclosing my test results. In addition, a
positive test result may be recorded in my medical record maintained at the hospital
and the laboratory
5. The hospital has strict laws and policies to keep the HIV testing result confidential from
anyone other than you
6. Hospital will make every attempt to ensure the confidentiality of my test result.
However, the possibility of unauthorized disclosure always exists. This might result in
some form of discrimination. Furthermore, if this test for HIV is positive or if additional
tests indicate that I have AIDS, this information must, by statute, be reported to the
State Health Authority (NACO).

4. I also understand that

1. I can refuse to be tested and my refusal will not affect my future care at the hospital.
2. If my test is positive, I can expect a post-test counselling about implication of the test
result
3. I have also been explained procedure of drawing blood and the minimal risk involved in
this

Signature and name of the person giving consent Date / Time

Signature and name of the person taking consent Date / Time