Confidential Diagnostic Test Consent Form

ALL information below must be completed and will be kept strictly confidential. Please sign this form before taking the HIV and/or screening test.

Event Details

Service Date *

Company Name *

Testing Site *

Personal Information

Title * Title

Gender *

Race Race

Marital Status

Initials *

Age *

Full First Name/s *

Surname *

Preferred Name

ID / Passport Number *

Date of Birth *

Preferred Language * Preferred Language

Medical Aid

Medical Aid Number

Kaelo Health Policy No.

In which Department do you work? *

Qualification Level *

Employment Status *

Employee Number

Contact Details

Cellphone Number *

Work Number

Extension

Home Number

Dropdown

Alternative Phone Number

Relation

Email Address

Ideal Contact Time *

Before 8am

8am - 5pm

After 5pm

OtherOther

Preferred method of contact *

Telephonic

SMS

OtherOther

Personal Declaration

By signing this personal declaration, I declare that I have read, understood and agreed to the following

I agree to the HIV, wellness and TB screening tests freely and voluntarily.
I understand that the wellness tests are screening tests and further investigations may be required in order to ascertain a definitive diagnosis.
I understand that there may 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 HIV 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 test and results.
I know that I can withdraw my consent to do the test.
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, nominated doctor and/health care practitioner/s and service providers assisting in my care.
I consent to all my medical information be communicated to my company funded clinic.

I agree *

Iagree to all the above and declare that the information completed above is true to the best of my knowledge.

Signature

Clear

Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP: 36931).
This product is underwritten by Centriq Insurance Company Limited (FSP 3417).

Statutory notice:

This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for Medical Scheme membership.

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