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Sterilization Consent Form

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LDSS-3134 (2/01) PATIENT NAME CHART NO. RECIPIENT ID NO. Sterilization Consent FORM HOSPITAL/CLINIC 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 asked for and received information about Sterilization from __________________________________.

Before _____ signed the . Name of Individual . consent form, I explained to him/her the nature of the sterilization

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