INFORMED CONSENT FOR HIV TESTING A

during pretest counseling or group test information I agree to be tested for HIV. Signature: Date: ... Sex partner is infected with HIV Wants to know HIV status Active Hepatitis B/C ... To be filled up by TESTING FACILITY only To be filled up by PHYSICIAN, CLINIC STAFF or COUNSELOR only 21 22 24 Month Day Year END

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  Testing, Counseling, Hepatitis, Hiv testing

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