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Print HWO034 (Rev. 3/07) NOTICE: CONSENT FORM 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

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How to fill out sterilization consent form english-hw0034

How to fill out sterilization consent form english-hw0034:

01

Start by carefully reading the form instructions. Make sure you understand the purpose and requirements of the form.

02

Provide your personal information accurately, including your full name, date of birth, and contact details.

03

Fill in the date of the sterilization procedure or indicate if it is scheduled in the future.

04

Consult with your healthcare provider regarding any specific procedures or options mentioned in the form, and provide the necessary information accordingly.

05

Review the risks and benefits section thoroughly. Initial next to each statement to confirm your understanding.

06

If applicable, provide information about your spouse or partner, including their name and contact details.

07

Indicate whether you have received counseling or have been informed about alternative forms of contraception. If so, sign and date the corresponding sections.

08

Carefully read the statements related to voluntary consent. Sign and date these sections to confirm your consent to the sterilization procedure.

09

If you have any questions or concerns, do not hesitate to seek clarification from your healthcare provider before signing the form.

10

Make a copy of the completed form for your records before submitting it to the relevant healthcare personnel.

Who needs sterilization consent form english-hw0034:

01

Individuals who are considering or have decided to undergo a sterilization procedure.

02

Any person who has received counseling regarding sterilization and has been provided with the necessary information about alternative forms of contraception.

03

Those who fully understand the risks, benefits, and implications of the sterilization procedure and are willing to provide their voluntary consent.

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