OPERATION LETTERHEAD FORM

* indicates required fields
Client
* First Name:
Middle Name:
* Last Name:
* Birth Date:
* Address 1:
Address 2:
* City:
* State:
* Country:
* Zip/Postal Code:
* Email Address:
* Re-enter Email Address:
Phone Numbers
Diagnosis
Clinician #1
Is this your current primary care physician?
Yes
No
Not Sure
* Name:
* Clinic/Hospital:
* Address:
* City:
* State:
* Country:
* Postal Code:
* Date of last visit:
To your best recollection, please describe the circumstances and process that led to your testing, treatment and/or diagnosis:
I may have been tested using:
Elisa?
Yes
No
Not Sure
Western Blot?
Yes
No
Not Sure
Viral Load?
Yes
No
Not Sure
Other?
Yes
No
Not Sure
Do you have a copy of your ELISA test results?
Yes
No
Not Sure
Do you have a copy of your WESTERN BLOT test results?
Yes
No
Not Sure
Do you have a copy of your VIRAL LOAD test results?
Yes
No
Not Sure
Do you have a copy of your PCR test results?
Yes
No
Not Sure
Upload copies of your test results
Are you currently taking any HIV/HAART Medications?
Yes
No
Are you currently taking any other prescription drugs?
Yes
No
Do you use recreational drugs?
Yes
No
Client Statement
The Client declares that all information given to the Consultant is, to the best of the Client’s knowledge, true and accurate and given to the Consultant in a good faith basis to resolve the issues presented to the Consultant and contemplated by this Agreement. The Client and Consultant agree that the damages from any false or misleading information given to the Consultant will be difficult to calculate.  As a result, the Client agrees that in the event the Client purposefully misleads the Consultant or provides false and misleading information to the Consultant, the Client will be liable for liquidated damages against the Client in an amount of US$100,000.00(One Hundred Thousand Dollars).
Do you AGREE or DISAGREE?
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