Consent Form Pm 330 - Department Of Health Services

CONSENT FORM

State of California -- Health and Human Services Agency

Department of Health Services

PM 330

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

I have asked for and received information about sterilization from

(Name of Individual to be sterilized)

consent

form,

explained

him/her the nature of

the

sterilization

. When I first asked for

(doctor or clinic)

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

operation

, the fact that it

I was told that I could decide not to be sterilized. If I decide not to be sterilized, my

(Name of procedure)

is intended to be a final and irreversible procedure and the discomforts, risks, and

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

benefits associated with it.

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

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

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

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

because it is permanent.

I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED

I informed the individual to be sterilized that his/her consent can be withdrawn

PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT

at anytime and that he/she will not lose any health services or any benefits provided

WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN.

by Federal funds.

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

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

least 21 years old and appears mentally competent.

He/She knowingly and

and could be provided to me which will allow me to bear or father a child in the

voluntarily requested to be sterilized and appears to understand the nature and

future. I have rejected these alternatives and chosen to be sterilized.

consequences of the procedure.

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

Date:

Signature of person obtaining consent

Day

(Name of procedure)

The discomforts, risks and benefits associated with the operation have been

explained to me. All of my questions have been answered to my satisfaction.

Name of Facility where patient was counseled

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

Address of Facility where patient was counseled

City

State

Zip Code

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 withholding of any

benefits or medical services provided by federally funded programs.

PHYSICIAN’S STATEMENT

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

Day

Shortly before I performed a sterilization operation upon

(Name of individual to be sterilized)

Last

I explained to him/her the nature of the

(Date of Sterilization),

Day

First

M. I.

sterilization operation

(Name of procedure)

hereby

consent

own

free

will

sterilized

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

risks and benefits associated with it.

by a

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

(Doctor’s name)

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

because it is permanent.

method called

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

(Name of procedure)

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

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

Federal funds.

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

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

operation to:

least 21 years old and appears mentally competent.

He/She knowingly and

voluntarily requested to be sterilized and appeared to understand the nature and

•

Representatives of the Department of Health and Human Services.

consequences of the procedure.

•

Employees of programs or projects funded by that Department but

only for determining if Federal laws were observed.

(Instructions for use of Alternative Final Paragraphs:

Use the first

paragraph below except in the case of premature delivery or emergency abdominal

I have received a copy of this form.

surgery when 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 below which is not used.

Date:

Signature of individual to be sterilized

Day

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

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

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

INTERPRETER’S STATEMENT

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

following circumstances (check applicable box below and fill in information

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

requested.)

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

Premature delivery date:

Individual’s expected date

form in

language and

Day

explained its contents to him/her. To the best of my knowledge and belief he/she

of delivery:

(Must be 30 days from date of patient’s signature).

understood this explanation.

Day

Date:

Emergency abdominal surgery; describe circumstances:

Signature of Interpreter

Day

Date:

Signature of Physician performing surgery

Day

PM 330 (1/99)

Consent Form Pm 330 - Department Of Health Services - 1999

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