Confidential Diagnostic Test Consent Form

HIV Wellness and TB Screening Tests

• I agree to the HIV, wellness and TB screening tests freely and voluntary.
• I understand that the wellness tests are screening tests and that further investigation may be required in order to ascertain a
  definitive diagnosis.
• I understand that there might be side effects from the needle prick and from drawing blood, including mild bruising, infection and
  light headedness, and do not hold Kaelo Consulting (Pty) Ltd or my employer liable for any damage or injury incurred.
• I understand that the HIV test will involve a saliva/blood sample to test for antibodies.
• I understand that my test results will be given to me in person.
• I have been informed about the nature, conduct, benefits, risks and implications involved in an HIV test.
• I received and understand all the relevant information about the tests and the results.
• I know that I can withdraw my consent at any time before the HIV test is conducted.
• I do not hold Kaelo Consulting (Pty) Ltd, my employer or the health professionals performing the test responsible for any
  consequences or reactions I may have regarding the test result.
• I consent to my details and results being communicated to my medical scheme, Kaelo Patient manager and/or nominated doctor.
• I consent to all my medical information being communicated to my company-funded clinic.