Transcription of CONSENT FOR STERILIZATION - Florida
{{id}} {{{paragraph}}}
Example: barber
CONSENT FOR STERILIZATION - Florida
Form Approved: OMB No. 0937-0166. Expiration date: 4/30/2022. 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 STATEMENT OF PERSON OBTAINING CONSENT . I have asked for and received information about STERILIZATION from Before signed the Name of Individual . When I first asked CONSENT form, I explained to him/her the nature of STERILIZATION operation Doctor or Clinic for the information, I was told that the decision to be sterilized is com- , the fact that it is pletely up to me. I was told that I could decide not to be sterilized. If I de- Specify Type of Operation cide not to be sterilized, my decision will not affect my right to future care intended to be a final and irreversible procedure and the discomforts, risks or treatment.
Consent for Sterilization: Form HHS-687 Author: U.S. Department of Health & Human Services Subject: This form allows an individual to provide consent for sterilization. Statements are also included for an interpreter, a person obtaining consent, and a physician.
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: