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Aziz Medical Center Aziz Medical Center

# 1, Street No. 16, F-6/3 309 A Canal Bank West
Islamabad. Tariq Chaudry Road
  Near PCSIR 1

  Lahore

UK TB SCREENING TEST Email: [email protected]

Medical Center City (Check One) Islamabad Lahore Date: 23-May-2023

Failure to provide accurate information about previous or current TB disease shall be communicated to
the home office UK and Public Health England (PHE) that may result in delay of the visa process.

Full Name: Ishtiaq Ahmed Date of Birth: 06-Feb-2003 Gender: Male

Place Of Birth: Peshawar Passport No: US 1177851 Educational Qualification: intermediate

Present Occupation: student Visa Category: Student

Address in Pakistan: Vill Muhammadzai P.O Gulozia Dalazak Road Teh: District Peshawar

Address in United Kingdom: Coventry university

Post Code (UK): CV15FB

1- Have you ever been screened for TB?  No , Give details:  
2- Have you ever been diagnosed with TB? No , (if yes) Give details:  
3- Have you ever had prolonged cough, fever, weight loss or night sweats?: No

4- Have you ever felt any enlarged lymph nodes?: No , (if yes) Site of body:  
5- (For Females only) If pregnant, No. of current weeks of pregnancy:

6- Number of accompanying children under 11 years of age:

  By checking the box I hereby confirm that the above information given by me is correct and I give consent for the
TB screening in accordance with the guidelines given to the medical Center by the UK Home Office.

____________________________
AMC_UK_OPD_19 (Signature of Applicant)

UNITED KINGDOM PRE ENTRY TUBERCULOSIS SCREENING PROGRAMME

 
Name: Ishtiaq Ahmed
Date of birth: 06-Feb-2003
Clinic location: Islamabad
Applicant’s Declaration:
I understand that:

I am required to undergo testing for pulmonary tuberculosis (TB), involving an X-ray and possibly sputum
tests, prior to applying for entry clearance to go to the UK;

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If my chest X-ray is abnormal, I will receive individual counselling and an explanation of the further testing
procedures.
If my chest X-ray is abnormal, and changes are suggestive of tuberculosis, regardless of whether these
changes are old or new, or if there are other clinical reasons to suspect TB, I will have to provide 3 sputum
samples which will be tested for TB with smear and culture. I understand that the results of sputum cultures
may take up to ten weeks
If sputum samples are necessary, I will be required to return for sputum collection on 3 consecutive mornings
starting within 7 days of my chest X-ray. If I fail to return within 7 days, I will forfeit the opportunity to obtain a
TB Certificate.
If the smear or culture shows the presence of TB bacteria, I will be referred for TB treatment. Treatment shall
be at my own expense; I will inform the TB treatment facility that I have close family contacts, who may need
evaluation for TB.
I have the right to refuse to undergo the TB assessment procedure and TB treatment, but accept such a refusal
may adversely impact on my UK visa application.
I understand that the physician has the final decision about whether I receive a Certificate

Female applicants: All female applicants will be asked about their last menstrual period to identify applicants who
possibly may be pregnant:

If I could be pregnant, I will be offered several alternatives; 1) a chest X-ray with protective shield; 2). I can
postpone the CXR (and TB clearance) until after delivery or 3) I can opt to provide 3 sputum samples for
laboratory examination.
I acknowledge that a CXR can carry a risk for the unborn child, but this risk is quite small in the second and
third trimester. I am therefore advised to consult the panel physician and may wish to consult my gynaecologist
to understand the risks before I take a chest X-ray. If I decide to submit to an X-ray, this shall be at my own
risk.

I hereby:

consent to undergo TB testing;

authorise you and your designated laboratory to store all relevant personal information collected during the
assessment process, including health records and chest X-ray;
authorise you and your designated clinics to share my personal details and assessment results with the UK
immigration authorities, the UK Department of Health, Public Health England and the UK National Health
Service.
I authorise you to share my assessment results with the health authorities of my country of residence, where
this is required by my country’s laws.I release and hold harmless the UK Government and you from any liability
for loss, injury suffered or other harm during, or as a result of, the TB assessment procedures

I have read this consent form, or had translated for me. I was invited to ask questions to clarify what was not clear
to me. I understand the content of this declaration.
 
Applicant's Signature: Date:
 
Ishtiaq Ahmed

For children, or adults without the mental capacity to give consent, I confirm that I am the parent or legal guardian
of the applicant and confirm that I give consent.
For adults who are not able to physically sign the form, I confirm that I am an independent witness and the applicant
has given their consent orally or by other non-verbal means.

 
Signature: Date:
 
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Relationship to applicant:

Statement of interpreter (if requried); I have translated the content of this document for the applicant to the best of
my ability and in a way in which I believe s/he can understand.
 
Signed Date:
 
Ishtiaq Ahmed

For female applicants who might be pregnant; I confirm that I have had the risks of having a chest X-ray in
pregnancy explained to me and I wish to carry on with the chest X-ray.
 
Signed Date:
 
Ishtiaq Ahmed

Statement of Physician (if required); I have explained the content of this document to the applicant and confirm that
the applicant has declined to go ahead with the assessment.
 
Signed Date:
 
Ishtiaq Ahmed

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