PIEDMONT OBSTETRICS AND GYNECOLOGY
SCREENING FOR AIDS/HIV IN PREGNANCY
Patients Name____________________________ Med Record #_______________
A recent controlled study demonstrated that treatment during pregnancy of a patient, for HIV, significantly decreased the passage or transmission of the HIV to her fetus. Newborns with positive HIV testing decreased by 65%.
Because of this, we feel that we should offer the HIV blood test to all pregnant patient in order to identify those at risk for transmission to their baby and to allow treatment while the infant is in utero.
We currently test similarly for hepatitis B and for syphilis.
The HIV antibody test detects the presence of antibodies to the AIDS virus. These antibodies are substances in the blood produced by the body following infection with the AIDS virus. This is not a test for AIDS. The test will not tell you if you have AIDS or an AIDS related condition. It does show whether you have been infected with the virus that can cause AIDS.
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I have been informed about the HIV antibody test. I have read or have had read to me, the contents of this form. I have had a chance to ask questions which were answered to my satisfaction.
I understand that my medical treatment may be changed if my test is positive and that this change in treatment may be beneficial to me. I also understand that letting others know about by test results could cause me problems in employment or insurance.
I understand that this test result will be part of my medical record. I understand that both my test results and my medical record are confidential and will be shared only with health care providers directly involved in my care. I may request that my test results or any part of my medical record be withheld at the time I give consent for release of that record. I understand that omissions may be obvious and lead to further inquiries, but no information will be released without my permission.
I understand that benefits and risks of this test. This test will cost $96.00 and is usually covered by insurance.
I DO DO NOT wish to have this test done.
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Patients Signature Date