DECLARATION BY PARTICIPANT
All fields are mandatory
I wish to withdraw from the NSW DBS HIV and Hepatitis C Test Program and understand that such withdrawal will not affect my routine treatment, my relationship with those treating me or my relationship with organisations involved in the program.
I understand the implications of withdrawing from the program, as stated in the Information and Consent Form. In the event that any outstanding questions arose, any questions I had regarding my withdrawal have been addressed by the Study Contact.
Your full name
I withdraw from the study due to the following circumstances