Sterilization Consent Form

STERILIZATION CONSENT FORM (NON-FEDERALLY FUNDED)

State of California—Health and Human Services Agency California Department of Public Health

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

When I first asked for the information, I was told 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 BE 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

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 days (not less than 72 hours).

I am at least 18 years of age.

OR

I am under 18 AND

I have entered into a valid marriage, OR

I am on active duty with the U.S. 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.

I was born on (Month) (Day) (Year)

I, , hereby consent of my own free will to undergo an operation intended to sterilize me, to be performed by by a method called .

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.

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 language and explained its contents to him/her. To the best of my knowledge and belief, he/she understood this explanation.

STATEMENT OF PERSON OBTAINING CONSENT

Before signed the consent form, I explained to him/her the nature of the sterilization 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 any 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 appears to understand the nature and consequence of the procedure.

I certify that I explained orally to the person to be sterilized the requirements for informed consent as set forth on this form and in applicable regulations.

Facility:

Address:

PHYSICIAN’S STATEMENT

Shortly before I performed a sterilization operation upon on ,

I explained to him/her the nature of the sterilization 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 waiver 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):

a. Premature delivery:

b. Emergency abdominal surgery (describe circumstances):

c. Date individual intended to be sterilized:

Patient waived the 30-day waiting period to days. (Not less than 72 hours.)