Consent For Sterilization printable pdf download

Form Approved: OMB No. 0937-0166

Expiration date: 12/31/2018

CONSENT FOR STERILIZATION

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.

STATEMENT OF PERSON OBTAINING CONSENT

CONSENT TO STERILIZATION

signed the

Before

I have asked for and received information about sterilization from

Name of Individual

. When I first asked

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

Doctor or Clinic

, the fact that it is

for the information, I was told that the decision to be sterilized is com-

pletely up to me. I was told that I could decide not to be sterilized. If I de-

Specify Type of Operation

cide not to be sterilized, my decision will not affect my right to future care

intended to be a final and irreversible procedure and the discomforts, risks

or treatment. I will not lose any help or benefits from programs receiving

and benefits associated with it.

Federal funds, such as Temporary Assistance for Needy Families (TANF)

I counseled the individual to be sterilized that alternative methods of

or Medicaid that I am now getting or for which I may become eligible.

birth control are available which are temporary. I explained that steriliza-

I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED

tion is different because it is permanent. I informed the individual to be

PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO

sterilized that his/her consent can be withdrawn at any time and that

NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER

he/she will not lose any health services or any benefits provided by

CHILDREN.

Federal funds.

I was told about those temporary methods of birth control that are

To the best of my knowledge and belief the individual to be sterilized is

available and could be provided to me which will allow me to bear or father

at least 21 years old and appears mentally competent. He/She knowingly

a child in the future. I have rejected these alternatives and chosen to be

and voluntarily requested to be sterilized and appears to understand the

sterilized.

nature and consequences of the procedure.

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

. The discomforts, risks

Signature of Person Obtaining Consent

Date

Specify Type of Operation

and benefits associated with the operation have been explained to me. All

my questions have been answered to my satisfaction.

Facility

I understand that the operation will not be done until at least 30 days

after I sign this form. I understand that I can change my mind at any time

Address

and that my decision at any time not to be sterilized will not result in the

PHYSICIAN'S STATEMENT

withholding of any benefits or medical services provided by federally

Shortly before I performed a sterilization operation upon

funded programs.

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

Date

Name of Individual

Date of Sterilization

, hereby consent of my own

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

free will to be sterilized by

, the fact that it is

Doctor or Clinic

Specify Type of Operation

intended to be a final and irreversible procedure and the discomforts, risks

by a method called

. My

and benefits associated with it.

Specify Type of Operation

I counseled the individual to be sterilized that alternative methods of

consent expires 180 days from the date of my signature below.

birth control are available which are temporary. I explained that steriliza-

I also consent to the release of this form and other medical records

tion is different because it is permanent.

about the operation to:

I informed the individual to be sterilized that his/her consent can

Representatives of the Department of Health and Human Services,

be withdrawn at any time and that he/she will not lose any health services

or Employees of programs or projects funded by the Department

or benefits provided by Federal funds.

but only for determining if Federal laws were observed.

To the best of my knowledge and belief the individual to be sterilized is

I have received a copy of this form.

at 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.

Date

Signature

(Instructions for use of alternative final paragraph: Use the first

You are requested to supply the following information, but it is not re-

paragraph below except in the case of premature delivery or emergency

quired: (Ethnicity and Race Designation) (please check)

abdominal surgery where the sterilization is performed less than 30 days

Ethnicity:

Race (mark one or more):

after the date of the individual's signature on the consent form. In those

Hispanic or Latino

American Indian or Alaska Native

cases, the second paragraph below must be used. Cross out the para-

Not Hispanic or Latino

Asian

graph which is not used.)

Black or African American

(1) At least 30 days have passed between the date of the individual's

signature on this consent form and the date the sterilization was

Native Hawaiian or Other Pacific Islander

performed.

White

(2) This sterilization was performed less than 30 days but more than 72

hours after the date of the individual's signature on this consent form

INTERPRETER'S STATEMENT

because of the following circumstances (check applicable box and fill in

If an interpreter is provided to assist the individual to be sterilized:

information requested):

I have translated the information and advice presented orally to the in-

Premature delivery

dividual to be sterilized by the person obtaining this consent. I have also

Individual's expected date of delivery:

read him/her the consent form in

Emergency abdominal surgery (describe circumstances):

language and explained its contents to him/her. To the best of my

knowledge and belief he/she understood this explanation.

Interpreter's Signature

Physician's Signature

Date

HHS-687 (10/12)

Consent For Sterilization

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