I certify that I have read and understand the questions in these forms; I acknowledge that I will have the opportunity to discuss my health history with my doctor. I will not hold my doctor or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of these forms.

In the event of an accidental exposure to blood or other bodily fluids through needle stick, cut, mucous membrane contact, or the like, the undersigned consents to appropriate tests for the presence of Hepatitis B & C and HIV, which is the virus believed to cause AIDS. The patient will be informed of any positive results, and all such results will be treated as confidential by Chimera Medical Services. There is no charge to the patient.