Post-Test Counseling Information on

Submitted Forms

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Post-Test Counseling Information on Submitted Forms

This should be completed if you already submitted the HIV Test Form, but the patient/client has returned to receive their HIV test result and has now been post-test counseled.

* Denotes required fields.

* Requested by:

* Facility and Facility ID #:

* Form ID (number under barcode):
*Client ID (HIV test number):
* Date of Pre-test:	* Date of Post-test:

Comments or Questions::

Please enter comments or questions here.

Questions: Contact Jamie Flemming at (785) 296-6545 or Fax: (785) 296-4197.

Post-Test Counseling Information onSubmitted Forms

Post-Test Counseling Information on Submitted Forms

Post-Test Counseling Information on

Submitted Forms