Chlamydia Screening Consent Form

Personal Information

Full Name Date of Birth Address Phone Number

Consent

I hereby consent to undergo chlamydia screening. I understand the purpose, risks, and benefits of the test, and my results will be kept confidential as per applicable laws and clinic policies.

I confirm that I have read and understood the above and voluntarily agree to be screened for chlamydia.

Signature

For Clinic Use Only

Received by Date Received