Fillable Form Hhs-687 - Consent For Sterilization - Arizona printable pdf download

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

__________

Before

signed the consent form, I explained to him/her the

I have asked for and received information about sterilization from

Vasectomy

nature of sterilization operation

, the fact that it is intended to be

Arizona Urology

. When I first asked for the information, I was told that

a final and irreversible procedure and the discomforts, risks and benefits

the decision to be sterilized is completely up to me. I was told that I could

associated with it.

decide not to be sterilized. If I decide not to be sterilized, my decision will

I counseled the individual to be sterilized that alternative methods of birth

not affect my right to future care or treatment. I will not lose any help or

control are available which are temporary. I explained that sterilization is

benefits from programs receiving Federal Funds, such as A.F.D.C. or

different because it is permanent.

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

I informed the individual to be sterilized that his consent can be withdrawn at

UNDERSTAND

THAT

THE

STERILIZATION

MUST

any time and that he/she will not lose any health services or any benefits

CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE

provided by Federal funds.

DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR

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

CHILDREN OR FATHER CHILDREN.

least 21 years old and appears mentally competent. He knowingly and

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

voluntarily requested to be sterilized and appears to understand the nature

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

and consequences of the procedure.

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

to be sterilized.

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

Vasectomy

. The discomforts, risks and benefits associated with the

_____________________________________________ ___________

operation have been explained to me. All my questions have been

answered to my satisfaction.

Signature of person obtaining consent

Date

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

ARIZONA UROLOGY

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

13555 W. McDowell Rd, Suite 203, Goodyear, AZ 85395

withholding of any benefits or medical services provided by federally

18555 N. 79

Ave, Suite E-105, Glendale, AZ 85308

funded programs.

10238 E. Hampton Ave, Suite 202, Mesa, AZ 85209

_____________

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

PHYSICIAN’S STATEMENT

___________

, hereby consent of my own free will to be sterilized by

Shortly before I performed a sterilization operation upon

____________________

__________________

on (

date of sterilization) ___________________

Vasectomy

by a method called

. My consent expires 180 days from the

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

date of my signature below.

Vasectomy

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

, the fact that it is intended to be a final and irreversible

about the operation to:

procedure and the discomforts, risks and benefits associated with it.

Representatives of the Department of Health and Human Services, or

I counseled the individual to be sterilized that alternative methods of birth

Employees of programs or projects funded by the Department but only for

control are available which are temporary. I explained that sterilization is

determining if Federal laws were observed.

different because it is permanent.

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

I have received a copy of this form.

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

benefits provided by Federal funds.

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

Signature

:_________________________________

least 21 years old and appears mentally competent. He knowingly and

voluntarily requested to be sterilized and appeared to understand the nature

and consequences of the procedure.

Date: _____________________________

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

Month Day Year

paragraph below except in the case of premature delivery or emergency

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

abdominal surgery where the sterilization is performed less than 30 days

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

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

Ethnicity:

Race (mark one or more):

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

□

Hispanic or Latino

American Indian or Alaska Native

which is not used.)

□

(1) At least thirty days have passed between the date of the individual’s

Not Hispanic or Latino

Asian

signature on this consent form and the date the sterilization was performed.

□

Black or African American

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

□

Native Hawaiian or Other Pacific Islander

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

□

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

White

information requested):

INTERPRETER’S STATEMENT

□

Premature delivery

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

Individual’s expected date of delivery: _______________________

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

□

Emergency abdominal surgery (describe circumstances) :

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

________________________________________

read him/her the consent form in _______________________________

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 (11/2006)

Form Hhs-687 - Consent For Sterilization - Arizona

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