Consent For Sterilization

Information you will need

• Who informed the patient?
• What's the operation called?
• What's the patient's name?
• Who's performing the operation?
• Is the patient Hispanic or Latino?
• Is the patient American Indian or Alaska Native?
• Is the patient Asian?
• Is the patient Black or African American?
• Is the patient Native Hawaiian or Other Pacific Islander?
• Is the patient White?
• Who's obtaining consent?
• What's the physician's name?
• What's the patient's date of birth?
• Why is the operation being performed early? (if applicable)
• What's the name of the medical facility?
• What's the address of the medical facility?
• What language was this form translated to?
• What's the sterilization date?
• What circumstances led to the emergency abdominal surgery?
• What's the expected delivery date?