HIV Treatment Consent Form and Patient Agreement
______I am entering the care of WHEAT Community Services (an HIV and STD prevention program) and the completeness and accuracy of care that I receive is based on the information I provide.
______I understand that any positive STD/STI/HIV/AIDS test results must be reported to the local health department in which I reside within 72 hours in accordance with the Florida State Law.
______I acknowledge that I have received a copy of the WHEAT Community Services Notice of Privacy Practices statement.
______There is a period of time (a “window”) after a person is infected with a STD/STI during which the test will read “non-reactive”. This window period can vary in length. It is important to tell the office if you think you’ve had a high-risk sexually disease or new other STI/STD exposure (unprotected sex) in the last few days. This may require different or additional medications to be prescribed to me.
______Taking a dose of my HIV medications or HIV prevention medications (PReP)every day may lower my risk of spreading HIV infection to others. This medicine does not completely eliminate my risk of getting other sexually transmitted diseases or HIV (if you are taking PReP), so I understand that condoms are still recommended. I acknowledge that no guarantees or assurances has been made to me.
______I understand that I have been scheduled have a follow up appointment every three months for follow up testing, evaluation and counseling and for monitoring and/or medication compliance as necessary.
______As part of a complete preventive health plan, vaccines will be recommended for me. My provider will review the benefits and risks of the vaccines.
By signing below, I understand and acknowledge the above information and consent to and agree to proceed with any testing and/or treatment proposed as well as to share this information with my providers and/or the local health department. I also certify that I was given an opportunity to ask questions and all of my questions have been satisfactorily answered.
______I understand that any positive STD/STI/HIV/AIDS test results must be reported to the local health department in which I reside within 72 hours in accordance with the Florida State Law.
______I acknowledge that I have received a copy of the WHEAT Community Services Notice of Privacy Practices statement.
______There is a period of time (a “window”) after a person is infected with a STD/STI during which the test will read “non-reactive”. This window period can vary in length. It is important to tell the office if you think you’ve had a high-risk sexually disease or new other STI/STD exposure (unprotected sex) in the last few days. This may require different or additional medications to be prescribed to me.
______Taking a dose of my HIV medications or HIV prevention medications (PReP)every day may lower my risk of spreading HIV infection to others. This medicine does not completely eliminate my risk of getting other sexually transmitted diseases or HIV (if you are taking PReP), so I understand that condoms are still recommended. I acknowledge that no guarantees or assurances has been made to me.
______I understand that I have been scheduled have a follow up appointment every three months for follow up testing, evaluation and counseling and for monitoring and/or medication compliance as necessary.
______As part of a complete preventive health plan, vaccines will be recommended for me. My provider will review the benefits and risks of the vaccines.
By signing below, I understand and acknowledge the above information and consent to and agree to proceed with any testing and/or treatment proposed as well as to share this information with my providers and/or the local health department. I also certify that I was given an opportunity to ask questions and all of my questions have been satisfactorily answered.
