TexasChristianUniversity
BROWNLUPTONSTUDENTHEALTHCENTER
STD/STITESTINGCONSENTFORM
Name__________________________________
CellPhone#___________________________Mayweleaveamessageonthisphone?YN
E-MailAddress________________________@tcu.eduMayweemailyou?YN
Iaminterestedingettingtestedforsexuallytransmitteddiseases(STD)/sexuallytransmittedinfection(STI).Iam
nothavinganysymptomstoday.IunderstandthatIcanseeamedicalproviderforaconsultationand/orexamination,
butIprefertoonlyhavelaboratorytestingdoneatthistime.YoumayelecttohaveapartialSTD/STIscreenorthefull
STD/STIscreen.
PartialSTD/STItesting
FullSTD/STItesting
Gonorrhea/Chlamydia$50.00
HIVtest
Syphilis
$60.00
$11.90
Gonorrhea/Chlamydia $50.00
HIV
HerpesSimplex
TotalCharge
$60.00
$30.53
$140.53
TheabovepricesquotedarewhentheclinicbillsyourstudentaccountortheTCUstudentinsurance.
Pleaseselectoneofthefollowingtestoptions:
YES NOIwouldliketobetestedforGonorrhea/Chlamydiaonly,andIunderstandthisisconsideredpartialtesting.
YES NOIwouldliketobetestedforHIVonly,andIunderstandthisisconsideredpartialtesting.
YES NOIwouldliketobetestedforSyphilisonly,andIunderstandthisisconsideredpartialtesting.
YES NOIwouldliketohavethefullSTD/STIscreentoday.Iunderstandthisselectionincludestestingfor
Gonorrhea/Chlamydia,HIVandHerpes.
Fortestingpurposepleasewriteinthetimeyoulasturinated.Timeurinated:_______________________
Pleaseinitialthefollowingstatementsandprovideyoursignaturebelow:
____IunderstandIwillnotseeamedicalprovidertodayandIamhereforasymptomaticSTD/STItestingonly.
____Iunderstandthatmystudentaccountorstudentinsurancewillbebilledfortoday’slaboratorycharges,
unlessIelecttopaywithcashtoday.
____Iunderstandthatadditionalchargesmaybeincurredtoproperlydiagnose.
04/15
SIGNED___________________________________________________________________Date____________________