Designated Medical Practitioner Handbook

Appendix VI: Acknowledgment of
HIV Post-test Counselling

This is to acknowledge that I received HIV post-test counselling from (name of counsellor) on several topics related to my HIV-positive condition, including an explanation of the test results, risk-reduction strategies such as partner notification, and a discussion on follow-up and care.

______________________
Applicant’s Signature

______________________
Counsellor’s Signature

______________________
Printed Name of Applicant

______________________
Printed Name

______________________
File Number

______________________

Signed at ___________________ this ___ day of _________ 200__.

DMP ____________________________________________

Affix DMP Stamp

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