BEFORE YOU TEST, PLEASE REVIEW THE FOLLOWING INFORMATION

Your authorizing physician has given you the following information on HIV Testing...

I am giving my permission for a blood test in order to detect whether I have antibodies to the HIV virus (Human Immunodeficiency Virus) or any other identified causative agent of AIDS in my blood. I understand that the test results will be used for the purposes of my medical care and treatment.

I understand that the test is performed by withdrawing a sample of my blood and conducting laboratory tests to determine the presence of antibodies to HIV. I understand that the results of the blood tests considered to be positive will be reported to the state department of health.

I further understand that a positive result does not mean I have AIDS, but that my blood has been exposed to the AIDS virus and antibodies to that virus are present in my blood. I understand that counseling concerning AIDS will be offered to me if my test results are found to be positive.

I have been informed and understand that test results, in a percentage of cases, may indicate that a person has antibodies to the virus when the person does not have the antibodies (a false positive result) or that the test may fail to detect that a person has antibodies to the virus when the person does in fact have these antibodies (a false negative result).

I understand that individuals with HIV/AIDS can adopt safer practices to protect uninfected persons from acquiring HIV.

I understand that my test results will be released to my physicians and other health care providers providing my care. I understand that my test results will be kept confidential to the extent provided by law. In addition, I understand that I may withdraw from the testing at any time, prior to the completion of laboratory tests.

I have been advised about the purpose, potential uses, limitations and meaning of the test results; the voluntary nature of the test; the right to withdraw at any time, prior to the completion of laboratory tests; and the confidentiality protections under the law.

I understand that the law prohibits discrimination based on an individual's HIV status and services are available to help with such consequences.

I understand that I can call 888-215-9543 to ask any questions about this informed consent. With the information presented above having been completely and clearly explained to me and all of my questions having been answered, I hereby authorize to test my blood for HIV infection.