Consent form
Consent for HIV testing
Read each statement and tick the box if you agree. You may ask questions, and you may decline.
Patient details
| Patient nameSpecimen Patient | Age / Sex42 y · Female | Phone+91 90000 00000 | BookingSPECIMEN-SUN-LB-00218 | Date24 Aug 2026 |
Tests this consent covers
| No. | Test | Sample |
|---|
| 1 | HIV 1 & 2 antibody (4th generation) | Serum |
Declaration — tick each statement you agree with
| No. | Statement | Agree |
|---|
| 1 | I confirm that the purpose of the test, the meaning of a reactive and a non-reactive result, and the confidentiality of my result have been explained to me in a language I understand. I consent to the collection of a blood sample for this test. I understand that I may withdraw this consent at any time before the sample is tested. | |
I agree to the test(s) listed above I do not agree
Signatures
| Patient / parent / guardian | Explained / counselled by | Witness |
|---|
| Name | Name | Name |
| Relationship to patient | Designation | Address / phone |
| SignatureDate & time: | SignatureDate & time: | SignatureDate & time: |
For laboratory staff — not part of the patient's declaration
Pre-test counselling is mandatory. Record the counsellor's name in the laboratory register; a reactive result is disclosed in person, never over the phone or by message.
Consent for HIV testing, version v2.1 · NACO National HIV Testing Guidelines · ICMR ethical guidelines · Document SPECIMEN/CS/2026/0007 · Retain the signed original with the laboratory record.