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Pm 284 sterilization consent form

Pm330 2026

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The document is a consent form for sterilization issued by the State of California's Health and Human Services Agency. It outlines the rights of individuals regarding their decision to undergo sterilization, emphasizing that they can withdraw consent at any time without losing benefits from federally funded programs. The form includes statements from both the individual seeking sterilization and the physician, confirming understanding of the procedure's permanence, risks, and alternatives. It also requires acknowledgment of age and mental competence.

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Click ‘Get Form’ to open the pm330 consent form in the editor.
Begin by filling in the name of the individual to be sterilized in the designated field. Ensure that all personal information is accurate.
In the 'Statement of Person Obtaining Consent' section, enter your name and details as the counselor. Clearly explain the nature of sterilization and its permanence.
Complete the date fields accurately, ensuring you follow up with a signature where required. This includes both the individual’s signature and yours as the person obtaining consent.
If applicable, fill out any interpreter statements if an interpreter was used during counseling. Ensure all explanations were understood by checking off relevant boxes.
Review all sections for completeness and accuracy before saving or exporting your completed form for submission.

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