Form Ldss 3134 – Fill Out and Use This PDF

LDSS-3134 (2/01)

STERILIZATION CONSENT FORM

PATIENT NAME

CHART NO.

RECIPIENT ID NO.

HOSPITAL/CLINIC

■ CONSENT TO STERILIZATION ■

I have asked for and received information about sterilization from

__________________________________. When I asked for the

(doctor or clinic)

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 will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible.

I 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 be sterilized by an operation know 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 thirty days after 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.

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

Month Day Year

I, ____________________________, hereby consent of my own

free will to be sterilized by _________________________________

(Doctor)

by a method called _____________________________. My consent

expires 180 days from the date of my signature below.

I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health, Education, and Welfare or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed.

I have received a copy of this form.

_____________________________________Date: ____________

Signature

Month Day Year

You are requested to supply the following information, but it is not required:

Race and ethnicity designation (please check)

□1	American Indian or	□	4	Hispanic
□2	Alaska Native	□
	Asian or Pacific Islander		5	White (not of Hispanic origin)

□3 Black (not of Hispanic origin)

■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.

_______________________________________ ______________

Interpreter

Date

■ STATEMENT OF PERSON OBTAINING CONSENT■

Before _____________________________________ signed the

Name of Individual

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 21 years old and appears mentally competent. He/She knowlingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure.

Signature of person obtaining consent

Date

Facility

Address

■ PHYSICIAN’S STATEMENT ■

Shortly before I performed a sterilization operation upon

____________________________________ on _______________

Name of individual to be sterilized Date of sterilization

_________________________________, I explained to him/her the

Operation

nature of the sterilization operation _____________________, the

Specify type of operation

fact that it is intended to be a final 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 a least 21 years old 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 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 thirty days have passed between the date of the individual’s signature on this consent form and the date sterilization was performed.

(2)This sterilization was preformed 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 and fill in information requested):

□1. Premature delivery

Individual’s expected date of delivery: ______________

□2. Emergency abdominal surgery: ___________________

(describe circumstances ): ____________________________

________________________________ ________________

PhysicianDate

SIGNATURE OF WITNESS

TITLE

X

REAFFIRMATION (to be signed by the patient on admission for Sterilization)

DATE