Sterilization Consent Form printable pdf download

State of California-Health

an~

Human Services Agency

CallfoP1la Jepartmenl of

P~b;ic

Health

STERILIZATION CONSENT FORM (NON-FEDERALLY FUNDED)

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

ROBERT G. PUGACH, MD

(Doctor or Conie)

When I first asked for the information, I was lold 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 to be sterilized, my decision will not affect my right

to future care or treatment. I understand that I can change my mind at any

time,

UNDERSTAND

THAT

THE

STERILIZATION

MUST

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 future, I have rejected these alternatives and chosen to be

sterilized,

I understand that I will undergo an operation known as a

BILATERAL VASECTOMY _ _ __

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 30 days

after I sign this form except in specific instances that have been fully

explained to me,

I wish to waive the 30·day waiting period to

.3.-

days (not less than

72 hours),

I am at least 18 years of age,

I am under 18

AND

I have entered into a valid marriage, OR

I am on active duty with the US, armed services, OR

I have received a declaration or emancipation pursuant to Section 64

of the Civil Code, OR

I am over 15 years old, live apart from my parents or guardians, and

manage my own financial affairs,

Iwasbornon __

~~~

____

~~~

(Month)

(Day)

(Year)

, hereby consent

of my own free will to undergo an operation intended to sterilize me, to be

performed by

ROBERT

G PLJGACH.

!~or)

byamethodcalled

BILATERAL vASECTOMY

I am not in labor and it has been at least 24 hours since I gave birth or

had an abortion, I am not seeking to obtain or obtaining an abortion at this

time,

I am not under the influence of alcohol or other substances that affect

my state of awareness,

I understand that I may have a witness of my choice present during the

time my consent is obtained,

My consent expires 180 days from the date of my signature below,

I have received a copy of this form,

(Date [MonthlOayfYear])

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 him/her the consent form in

ianguage

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

knowledge and

belief, he/she understOOd this explanation.

PM 284 iENGISP} (7107)

STATEMENT OF PERSON OBTAINING CONSENT

Before _________________-,-_____________ signed the

(Name of Indivlouaf)

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

-:-:-:---:--:--.--.-:--,.--;:----c---.-:-----::-;------;---.-c:-'

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 his/her consent can be

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

any benefits provided by federal funds.

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

at least

',8

years old, or meets the necessary age requirements under

applicable regulations, and appears mentally competent. He/She knowingly

and voluntailly requested to be sterilized and appears to understand the

nature and consequence of the procedure.

I certify that

explained orally to the person to be sterilized the

reqUirements for informed consent as set forth on this form and in applicable

regulations

(Signature

Person Obtaming Consent)

(Date)

ROBERT G. PUGACH, MD

3801

KATELlI~'~VE.~

STE. 110,

AMI;L2s~'

C.....

90720

PHYSICIAN'S STATEMENT

Shortly before I performed a sterilization operation upon

I explained to him/her the nature of the sterilization operation, _ _ _ __

BI LATERAL VASECTOMY

(Specify type of 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 his/her consent can be

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 least 18 years old, or meets the necessary age requirements under

applicable regulations. 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, or patient watver where the sterilization is performed

less than 30 days after the date of the 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 30 days have passed between the date of the individual's

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

2, I certify that 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 because of the following circumstances (check applicable box

and fill In information requested)

Premature delivery

IndiVidual's expected date of delivery _______

Emergency abdominal surgery (descnbe circumstances)'

Date Individual Intended to be sterilized ___,.,,"" ____________

Patient waived the 30·day waiting period to __________ days,

(Not less than 72 hours)

(Date)

Page 1

Sterilization Consent Form

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