• At-Home HIV Test request

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  • CONSENT FORM FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIGEN AND/OR ANTIBODY TEST

  • I have been informed that an oral sample from my mouth will be tested for antigens and/or antibodies to the Human Immunodeficiency Virus, the virus that causes AIDS.
     
    I acknowledge that I have been given an explanation of the test, including it's uses, benefits, limitations, and the meaning of the test results.

    I have been informed that the HIV test results are confidential and shall not be released without my written permission, except to: and as permitted under state law.

  • I understand that I have the right to withdraw my consent for the test at any time before the test is complete.

    I acknowledge that I will be provided with a copy of the pamphlet "What You Need to Know about HIV Testing." I will be given the opportunity to ask questions concerning the test for HIV antigens and/or antibodies, and I understand that my questions will be answered by the test counselor.

    I understand that I will be contacted by a Corktown Health test counselor for follow-up.

    A signed copy of this consent form will be included with my test kit.

    By my signature below, I consent to be tested for HIV

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