470-0835 (Rev. 02/23)
Iowa Department of Health and Human Services
Consent for Sterilization
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 requested and received information about sterilization from
. When I first requested the
doctor or clinic
information, I was informed the decision to be sterilized is completely up to me. I
was also informed 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 Family
Independence Program (FIP) or Medicaid that I am currently 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 informed of temporary methods of birth control that are available and could
be provided to me that would allow me to bear or father a child in the future. I
have rejected these alternatives and have chosen to be sterilized.
I understand that I will be sterilized by an operation known as a
.
The discomforts, risks, and benefits 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. 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 ______________________
I
,
hereby consent of my own free will to be sterilized by
, by a method called
doctor
.
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 and Human Services or
• Employees of programs or projects funded by that Department,
but only for the purpose of determining if federal laws were observed.
I have received a copy of this form.
Month
Day
Year
The following race and ethnicity information is requested, but is not required:
Race and ethnicity designation (please check):
White (not of Hispanic origin)
Asian or Pacific Islander
Black (not of Hispanic origin)
American Indian or Alaska Native
Hispanic
INTERPRETER’S STATEMENT
If an interpreter is provided to assist the person to be sterilized:
I have translated the information and advice presented orally to the person 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.
Date
STATEMENT OF PERSON OBTAINING CONSENT
Before
signed the
name of person
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 person to be sterilized that alternative methods of birth control are
available that are temporary. I explained that sterilization is different because it is
permanent.
I informed the person 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 person to be sterilized is at least 21
years old and appears mentally competent. He/She knowingly 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 person to be sterilized
date of sterilization operation
I explained to him/her the nature of the sterilization operation
, the fact that it is intended to be a
specify type of operation
final and irreversible procedure and the discomforts, risks and benefits associated
with it. I counseled the person to be sterilized that alternative methods of birth
control are available that are temporary. I explained that sterilization is different
because it is permanent. I informed the person 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 person to be sterilized is at 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
person’s signature on the consent form. In those cases, the second paragraph
below must be used. Check the appropriate box below.
At least 30 days have passed between the date of the person’s signature on
this consent form and the date the sterilization was performed.
This sterilization was performed less than 30 days but more than 72 hours
after the date of the person’s signature on this consent form because of the
following circumstances (check applicable box and fill in information
requested):
Premature delivery; person’s expected date of delivery
Emergency abdominal surgery: (describe circumstances):
Date