1039a-General-Consent-Form

Before you give your consent to treatment, be sure you understand the information given below. If you have any questions, staff will be happy to speak with you about them. After you have read this disclosure form, and are sure you understand the information about the services available from Project Vida Health Center (PVHC), you must sign this form to indicate your understanding and consent to services and/or treatment for yourself or your minor child. You may ask for a copy of this form. PVHC does not permit denial of services due to pre‑existing conditions or provide any barrier to care due to a person's past or present health condition.

I, the undersigned, understand that I must have a physical assessment or examination which may include, but is not limited to, testing for the following: cervical cancer (Pap smear), breast exam, testicular exam, laboratory test for anemia, diabetes, cholesterol, sexually transmitted diseases – including HIV – or other tests. I give my permission for any screening or diagnostic tests necessary to complete my physical examination in receipt of primary health care or family planning services. All procedures and services will be fully explained to me as will the risk or consequences involved. I understand that I may be responsible for payment of laboratory tests ordered by PVHC clinicians.

I understand that I will receive information and educational counseling about my health and/or about all methods of birth control (including birth control pills, IUDs, Norplant, condoms, diaphragms, and others) along with information on the use, method of administration, effectiveness, advantages, disadvantages, and side effects of each method when receiving primary health care or family planning services. I understand that no guarantees are made concerning the results of treatment or the effectiveness of any birth control method.

I understand that tests for the detection of sexually transmitted diseases may be conducted and that, according to the law, positive test results must be reported to the Department of Health. I understand that the test used by PVHC to detect the HIV virus does not diagnose AIDS (Acquired Immune Deficiency Syndrome). The test is one that detects the presence of antibodies to the HIV virus, but not the virus itself. I understand that if the first test is positive, other tests will be done. I understand that there are certain risks in having a test for HIV performed. A small percentage of tests may give a “false positive” or a “false negative” result. I understand that there may be a chance that I have been exposed to HIV and my body may not yet have made the antibodies, which can be detected by the test, and that I may need to repeat the tests at a later date. I understand that neither PVHC nor the Texas Department of State Health Services has warranted the accuracy of the test results. PVHC does not deny services due to non‑HIV related conditions.

I understand that my medical records are confidential and my protected health information (PHI) will not be released to any outside person or agency without my written permission except as outlined here or in PVHC’s Notice of Privacy Practices. I understand that in case of abuse or medical emergencies a referral for further services may be made, as required by law. Further, in all cases of abuse or suspected abuse (adult or minor) a report to a legal authority will be made as applicable and required by law.

I understand that a clinician will be available to answer any questions I may have concerning my health, and/or that of my minor child. I am responsible for any additional follow‑up care that is recommended, including care that is not available through PVHC clinics, and I will be given information about how to get medical care after clinic hours or in case of an emergency.

I give permission to Project Vida Health Center, its staff, and all medical personnel providing services under its sponsorship to provide health services to the patient identified on this form. I consent to the use and disclosure of my PHI as described in PVHC’s Notice of Privacy Practice. I certify that I have read, or have read to me, the above consent for service and I fully understand this information.