3rd Floor 158 Jan Smuts Avenue
Rosebank 2196
PO Box 950 Parklands 2121 South Africa
Tel: + 27 11 880 4821 Fax: +27 11 880
6084
web: www.bizwell.co.za and
www.sabcoha.org
HIV COUNSELLING AND TESTING (HCT) POST-TEST INFORMED CONSENT FORM
FIRST NAME
SURNAME
GENDER
IDENTITY NUMBER
NAME OF TESTER
SIGNATURE OF TESTER
SCREENING TEST
CONFIRMATORY TEST
BATCH NUMBER
BATCH NUMBER
EXPIRY DATE
EXPIRY DATE
TEST RESULT
TEST RESULT
If HIV antibody negative:
1.
I have been informed that my rest result is HIV antibody negative but this does not guarantee that I am not infected with HIV as I
may be in the window period. I accept responsibility to have another test in
time.
2.
I have discussed prevention strategies to assist me to reduce my risk of HIV exposure to stay HIV negative.
If HIV antibody positive:
1.
I have been informed that my test result is HIV antibody positive which means that I am infected with HIV.
2.
I accept responsibility for protecting myself against re-infection and preventing infection of my sexual partner/s.
3.
I understand that HIV is a chronic progressive illness that can be proactively managed.
4.
I understand that my next step should be to have my blood taken for a CD4 count to determine the stage of my HIV infection. This
will determine the treatment that I need at this stage of disease progression.
5.
I have been given a results card and/or referral letter and specific information about where, when and how to access applicable
treatment options including contact information, times that services are available, forms, costs and documentation needed such
as an identity book or passport.
6.
I understand the critical link between TB and HIV and I am fully informed of the signs and symptoms of TB.
7.
I understand the link between STIs and HIV and I am fully informed of the signs and symptoms of STIs.
8.
I understand that I do not have to disclose my HIV status to anyone until I am ready. But I also understand the necessity of
disclosing my HIV status to my sexual partner/s so that they can access testing and treatment if necessary. Disclosure is a process
for which on-going counselling can provide guidance and support.
9.
I have been counselled about possible emotional responses and their impact on me and my future lifestyle choices.
10. I understand the importance of positive living, good nutrition and early diagnosis and treatment of all future illnesses.
By signing this consent form I agree that the HCT service provider may [tick next to the option you are agreeing to in the block below]:



Take blood for further diagnostic testing or disease staging.
Contact me to share the above results and/or follow-up on treatment registration.
Share my results with my treatment and/or EAP service provider who may contact me to offer relevant services and support.
By completing the contact information below you give permission to the HCT provider to contact you after testing to follow-up referral:
CONTACT NUMBER
ADDRESS
DAYS & TIMES
Post-test counselling waiver:
*recommended for repeat testers only or if the counsellor is satisfied that the client has adequate knowledge and understanding
By ticking in this block, I waive my right to post-test counselling. I indemnify the company, service provider and/or counsellor against
any liability arising from this waiver.
I have been referred to
[treatment site/service provider] and accept responsibility for accessing
wellness, treatment and, care and support services offered. Signed at ________
____________ (place) on this __
__
(day) of _____
______ (month) by:
Client contact number:
Client signature:
Post-test counsellor name:
Post-test counsellor signature: