STD Testing Consent Form

Personal Information

Full Name Date of Birth Email Address Phone Number

Consent Statement

I understand that I am being tested for one or more sexually transmitted diseases (STDs), including but not limited to Chlamydia, Gonorrhea, Syphilis, Human Immunodeficiency Virus (HIV), and/or others as applicable.

I authorize the release of my testing results to the healthcare provider(s) involved in my care.

I understand that all information will be kept confidential as required by law.

I have read and understand the information provided above.