Sterilization Consent Form printable pdf download

Sterilization Consent Form

Patient Consent

Name:

Phone:

Address:

ID No.:

Chart No.:

I, the undersigned…

Verify that I am over

years of age.

Understand the pain, discomfort, risks, benefits and recovery time associated with this procedure.

Understand that this procedure is irreversible and permanent.

Understand that after this procedure I will be unable to conceive, bear or father children.

Have been informed of other birth control options, including

Have rejected the aforementioned temporary options and have chosen sterilization.

Understand that I have

days until the surgery and that I can revoke my consent at any time

without penalty or loss of benefits

Will undergo the procedure

for the purpose of sterilization.

Verify that the doctor has explained the aforementioned information to me in detail and has answered all

questions I had.

Patient Signature

Date

Physician Statement

Doctor Name:

Hospital:

Operating Surgeon Name:

I, the consulting physician…

Hereby state that to the best of my knowledge, the patient is over

years of age, mentally

sound and physically capable of undergoing the surgery.

Explained the resulting benefits, risks, pain and discomfort of this procedure to the patient.

Believe that the patient understands that the procedure will result in permanent, irreversible sterility.

Ensured that the patient voluntarily consented to this operation and understands that consent can be

revoked at any time.

Understand that I must wait

days before ordering the procedure unless the patient either goes into

premature labor or has emergency abdominal surgery.

Will refer the patient to

for the purpose of the sterilization procedure.

Swear that I have explained the aforementioned information to the patient in detail and have answered all

questions asked.

Physician Signature

Date

Witness Statement

, hereby swear and confirm that I witnessed the physician inform the

patient of the aforementioned information and that the witness did sign the document in his or her own hand.

Witness Signature

Date

Sterilization Consent Form

Related Articles

Related forms

Related Categories