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Click ‘Get Form’ to open the hiv hcv test formpatient in the editor.
Begin by filling out the Facility Information section. Enter the Facility Name where the test was conducted.
Next, move to Client Information. Fill in your Last Name, First Name, Date of Birth, and Telephone Number.
Indicate your Gender Identity by selecting one of the options provided.
For the Chembio SURE CHECK® Rapid HIV Test Results, mark whether the result is Negative or Preliminary Positive and fill in the Collection Date.
Repeat step 5 for the OraSure OraQuick® Rapid HCV Test Results.
Complete the Confirmatory HIV and HCV Test Results sections by marking Negative or Positive as applicable and entering Collection Dates.
If you received a copy of this test result form, check the Counselor box. Ensure both Counselor’s Signature and Client’s Signature fields are signed and dated.
Finally, add any additional notes if necessary before saving your completed form.

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