MPL – 07

FORMAT FOR ACCEPTING SAMPLES FOR HIV TESTS

Before accepting a blood sample for HIV test, consent from the patient to carry out the test
must be obtained. The format of the consent letter is given below. If necessary the same
should be translated into a regional language and patients signature obtained. It is also
necessary to obtain from the doctor a letter stating that he will undertake pre and post test
counseling of the patient. Both these documents should be kept under lock and key and be
available for Audit by NABL auditors.

Informed Consent for HIV/AIDS Testing Given by the Patient

1. I have been informed about HIV/AIDS and fully aware of the consequences of the
outcome of the test. I have been informed about the limitations of the test that the test is
not absolutely confirmatory of my HIV/AIDS status.
2. I have been properly counseled before doing this test and will be receiving counseling
once the result is available.
3. I am aware that this test cannot be imposed on me under any circumstances without my
prior permission. I understand that I have the right to refuse this test.
4. This is being done for purely medical reasons and not any medico-legal complications.
5. I am hereby giving permission to obtain the blood for HIV/AIDS testing, doing the tests,
generating the result, and transmission of the results.

Name/     : Age/    :

Sex/       :

Address/         :

Signature of Patient/                 : Date/     :

Page 1 of 2
 MPL – 07

REQUEST FOR HIV/AIDS TESTING ASKED BY THE DOCTOR

UNDERTAKING FOR GIVING PRE-TEST & POST-TEST COUNSELLING AND

FOR OBTAINING INFORMED CONSENT FOR HIV TESTING

Counselor’s Commitment :

I, hereby state that the patients will be counseled about the HIV test and will be
explained about the implications of the test result. All details pertaining to HIV. Its
transmission, prevention, testing procedures, its limitations and interpretation of results will
be explained.

Declaration:

This is to certify that, I will give pre-test counseling and also post-test counseling to the
patients referred by me for HIV testing, in line with NACO Guidelines.
I, the counselor, will do everything possible to assure that the consent of the
counseling session and the test result will be kept confidential.

Signature of the Physician _____________________________

Name of the Physician________________________________

Date_____________

Place _________________________

Page 2 of 2