CERTIFICATE OF ACCURACY

Should a physician insist that you, or your child, test, insist that they first sign this document. If they are certain that HIV tests are accurate, they should agree without hesistation to stand behind their recommendations and provide, in writing, their assurance for your health and safety.

Certificate of Assurance of Accuracy For HIV Antibody Test:

Name of Patient:..............................................................................................Date:...............

Doctor/Clinician Instructions: Initial each statement, sign and date at bottom of page.

As the Doctor/Clinician recommending and/or administering the HIV antibody test (ELISA and Western Blot), I hereby certify with a reasonable degree of scientific certainty that the aforementioned tests performed by my office/clinic will:

......Produce accurate and reliable results;

......Indicate active infection with HIV;

......Will not cross-react with any of the following medical or biomedical conditions producing a false positive result:

Amorrhea; antigenic stress for from any non-HIV source; candidiasis; cholera; cigarette smoking; cytomegalo virus (CMV); Epstein-Barr; flu or prior flu vaccination; foreign semen; hemorrhoids; hepatitis or hepatitis vaccine; herpes simplex; high blood globulin levels (from drug and/or alcohol use); malaria; mycobacterium; nitrites; normal cellular proteins such as actin or myosin; parasitic infections; pregnancy or prior pregnancy; swollen glands; tuberculosis; use or recreational or pharmaceutical drugs; vaginal ulceration;

......Can be regularly reproduced by other qualified labs;

......That the results will in no way be based on, or determined by information in this patient's medical history that may indicate s/he may belong, or may have belonged to one or more of the groups identified as "at risk" for AIDS.

In addition, I hereby certify that, due to the severe emotional trauma following an HIV positive test result and the serious physiological harm caused by the pharmaceutical drugs used to treat HIV, if it is later discovered that I/my office/clinic gave this patient a false positive test result, and/or if the HIV antibody test being administered today proves to be non-specific, unreliable and/or inaccurate, that I would be liable for damages due to emotional and/or physical suffering and distress including death.

Name of office/clinic:.................................................................

Name of physician/clinician:.......................................................

Signature of physician/clinician:.................................Date:.........

Signature of patient:.................................................Date:..........