STERILIZATION CONSENT FORM Form

NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.

CONSENT TO STERILIZATION

I have asked for and received information about sterilization from

When I asked for the (doctor or clinic) information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible.

I UNDERSTAND THAT THE STERILIZATION JUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN.

I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the Mure. I have rejected these alternatives and chosen to be sterilized.

I understand that I will be sterilized by an operation know as a

The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs.

I am at least 21 years of age and was born on

hereby consent of my own free will to be sterilized by

by a method called

My consent expires 180 days from the date of my signature below. I also consent to the release of this form an other medical records about the operation to: Representatives of the Department of Health, Education, and Welfare or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form.

Signature

Date

You are requested to supply the following information, but it is not required:

Race end ethnicity designation (please check)

1 American Indian or Alaska Native

2 Asian or Pacific Islander

3 Black (not or Hispanic origin)

4 Hispanic

5 White (not of Hispanic origin)

INTERPRETER'S STATEMENT

If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent.

I have also read his/her the consent form in

language and explained its contents to him/her. To the best of my knowledge and believe he/she understood this explanation.

Interpreter

Date

STATEMENT OF PERSON OBTAINING CONSENT

Before

signed the Name of Individual consent form, I explained to him/her the nature of the sterilization operation,

the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent

I informed the individual to be sterilized that this/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provide by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowlingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure.

Signature of person obtaining consent

Date

Facility

Address

PHYSICIAN'S STATEMENT

Shortly before I performed a sterilization operation upon

I explained to him/her the nature of the sterilization operation

the fact that it is intended to be a final irreversible procedure and the discomforts, risks and benefits associated with il

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization different because it is permanent.

I Informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provide by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is a least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.

(Instructions for use of alternative final paragraphs): Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of individual's signature on the consent form. In those cases , the second paragraph below must be used. Cross out the paragraph which is not used.)

(1) At least thirty days have passed between the date of the individual's signature on this consent form the date sterilization was performed.

(2) This sterilization was preformed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable and fill in information requested):

1 Premature delivery

2 Emergency abdominal surgery

Individual's expected date of delivery (Premature delivery)

Emergency abdominal surgery

(desaibe circumstances )

Physician

Date

THE FOLLOWING MUST BE COMPLETED FOR STERILIZATIONS PERFORMED IN NEW YORK CITY WITNNESS CERTIFICATION

do certify that on

I was present while the counselor read and explained the consent form to

and saw the patient sign the consent tonn in his/her handwriting.

SIGNATURE OF WITNESS

TITLE

DATE

REAFFIRMATION (to be sianed bv the oalient on admission for Sterilization)
I certify that I have carefully considered all the infonnation, advice and explanations given to me at the time I originally signed the consent form.
I have decided that I still want to be stelilized by the procedure noted in the ordinal consent form, and I hereby affinn that decision.

SIGNATURE OF PATIENT

DATE

SIGNATURE OF WITNESS

DATE

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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