Form Dmap 742b - Ages 15-20 - Consent To Sterilization Form - 2011 Page 2
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2Statement of Person Obtaining Consent
Before ___________________________(name of
individual to be sterilized that his/her consent can
individual) signed the consent form, I explained
be withdrawn at any time and that he/she will not
to him/her the nature of the sterilization operation
lose any health services or any benefits provided
__________________, the fact that it is intended
by Federal funds.
to be a final and irreversible procedure and the
To the best of my knowledge and belief the
discomforts, risks and benefits associated with
individual to be sterilized is between 15-20 years
it. I counseled the individual to be sterilized that
of age and appears mentally competent. He/
alternative methods of birth control are available
She knowingly and voluntarily requested to be
which are temporary. I explained that sterilization
sterilized and appears to understand the nature
is different because it is permanent. I informed the
and consequences of the procedure.
Signature of Person Obtaining
Facility____________________________________
Consent___________________________________
Address___________________________________
Date______________________ (month/day/year).
__________________________________________
Physician's Statement
Shortly before I performed a sterilization
emergency abdominal surgery where the
operation upon _______________________(name
sterilization is performed less than 30 days
of individual to be sterilized) on _________
after the date of the individual’s signature on
(date of sterilization operation), I explained to
the consent form. In those cases, the second
him/her the nature of the sterilization operation
paragraph below must be used. Cross out the
___________________________(specify type of
paragraph which is not used.)
operation), the fact that it is intended to be a final
(1) At least 30 days have passed between date of
and irreversible procedure and the discomforts,
the individual’s signature on this consent form
risks and benefits associated with it. I counseled
and the date the sterilization was performed.
the individual to be sterilized that alternative
(2) This sterilization was performed less than 30
methods of birth control are available which
days but more than 72 hours after the date
are temporary. I explained that sterilization is
of the individual's signature on this consent
different because it is permanent. I informed the
form because of the following circumstances
individual to be sterilized that his/her consent can
(check applicable box and fill in information
be withdrawn at any time and that he/she will not
requested):
lose any health services or benefits provided by
Federal funds.
q Premature delivery: Individual's expected
To the best of my knowledge and belief the
date of delivery ____________________.
individual to be sterilized is between 15-20 years
q Emergency abdominal surgery (describe
of age and appears mentally competent. He/
She knowingly and voluntarily requested to be
circumstances):______________________
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
Physician’s Signature________________________
Date___________________ (month/day/year).
DMAP 742B (Rev. 07/11)
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