Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
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64<strong>St<strong>and</strong>ards</strong> <strong>for</strong> female <strong>and</strong> male <strong>Sterilization</strong> servicesAnnexure 4In<strong>for</strong>med Consent Form <strong>for</strong> <strong>Sterilization</strong>Operation/Re-sterilization1. Name of client: Shri/Smt.............................................................................................................2. Name of spouse: Shri/Smt .........................................................................................................Address ......................................................................................................................................................................................................................................................................................................................3. Name of father: Shri......................................................................................................................Address ...................................................................................................................................................4. Religion .............................................................................................................................................5. Educational qualifications...........................................................................................................6. Business/occupation.....................................................................................................................7. Operating centre..............................................................................................................................I, Smt/Shri .................................................., hereby give consent <strong>for</strong> my sterilization operation. Iam married <strong>and</strong> my husb<strong>and</strong>/wife is alive. My age is ............................ years <strong>and</strong> my husb<strong>and</strong>’s/wife’s age is ............................ years. We have ............................ male <strong>and</strong> ............................ femaleliving children. The age of my youngest living child is ............................ years.I am aware that I have the option of deciding against the sterilization procedure at any timewithout sacrificing my rights to other reproductive health services.a)b)I have decided to undergo the sterilization/re-sterilization operation on my ownwithout any outside pressure, inducement or <strong>for</strong>ce. I declare that I/my spouse hasnot been sterilized previously (may not be applicable in case of re-sterilization).I am aware that other methods of contraception are available to me. I know that<strong>for</strong> all practical purposes this operation is permanent. I also know that there are still
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