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Click ‘Get Form’ to open the Sterilization Consent Form in the editor.
Begin by entering your Client Medicaid or DSHS Client Number at the top of the form. This is essential for identification purposes.
Select whether this is an initial submission or a corrected form by checking the appropriate box.
Fill in the date you signed the form using the month/day/year format.
In the 'Consent to Sterilization' section, provide details about your doctor or clinic and specify the type of operation you are consenting to.
Complete your personal information, including your birthdate and signature, ensuring all fields are filled accurately.
If applicable, have an interpreter complete their statement and sign it, followed by the person obtaining consent.
Finally, ensure that all signatures are dated correctly before submitting your completed form.

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How long is a sterilization form good for?

30 days (but not more than 180 days) must pass after the sterilization consent form has been signed. The 30 days starts the day after the consent is signed. Private Pay patients may request in writing that procedure be performed in less than 30 days.

What consent is required for sterilization?

STATEMENT OF PERSON OBTAINING CONSENT To the best of my knowledge and belief the individual 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 consequences of the procedure.

What are the forms of surgical sterilization?

There are two main methods of sterilization: tubal ligations and vasectomies. Both are safe and nearly 100% effective in preventing pregnancy.

How to request sterilization?

How to ask for a sterilisation. If youre thinking about having a sterilisation, you can make an appointment at your GP surgery or a sexual health clinic. A nurse or doctor will explain whats involved, the different options available, the possible risks and answer any questions.

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