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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F01164 (10/08)STATE OF WISCONSIN Wis. Admin. Code DHS 107.06(3)(e)FORWARDHEALTHCONSENT FOR STERILIZATION NOTICE: YOUR
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How to fill out consent for sterilization f-01164

01
Obtain the consent form F-01164 from the appropriate healthcare provider or facility.
02
Fill out the form completely, providing all necessary information such as your name, date of birth, address, and contact information.
03
Read the information provided on the form carefully to understand the risks and benefits of sterilization.
04
Sign and date the form in the presence of a witness, who must also sign and date the form.
05
Return the completed form to the healthcare provider or facility where you received it for further processing.

Who needs consent for sterilization f-01164?

01
Any individual who is considering undergoing sterilization procedure must fill out consent form F-01164. This includes both men and women who are of legal age and sound mind.
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Consent for sterilization f-01164 is a legal document signed by a patient to give permission for a sterilization procedure.
Any patient who will be undergoing a sterilization procedure is required to file consent for sterilization f-01164.
Consent for sterilization f-01164 must be filled out by the patient or their legal guardian, providing all required information and signatures.
The purpose of consent for sterilization f-01164 is to ensure that the patient fully understands the risks and benefits of the sterilization procedure and is giving informed consent.
Consent for sterilization f-01164 must include the patient's name, date of birth, the type of sterilization procedure, the date of the procedure, and signatures of the patient and the provider.
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