Standards for Female and Male Sterilization Services - STATE ...

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64Standards for female and male Sterilization servicesAnnexure 4Informed Consent Form for SterilizationOperation/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 for my sterilization operation. Iam married and my husband/wife is alive. My age is ............................ years and my husband’s/wife’s age is ............................ years. We have ............................ male and ............................ 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 force. 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 thatfor all practical purposes this operation is permanent. I also know that there are still
Standards for female and male Sterilization services 65some chances of failure of the operation for which the operating doctor and thehealth facility will not be held responsible by me or by my relatives or by any otherperson whomsoever.c)d)e)f)g)h)i)j)I am aware that I am undergoing an operation that carries an element of risk.The eligibility criteria for the operation have been explained to me, and I affirm thatI am eligible to undergo the operation according to the criteria.I agree to undergo the operation under any type of anaesthesia that the doctor/health facility thinks suitable for me and to be given other medicines as consideredappropriate by the doctor/health facility concerned.If, after the sterilization operation, I/my spouse experience (s) a missed menstrual cycle,then I/my spouse shall report within two weeks of the missed menstrual cycle to thedoctor/health facility and may avail of the facility to get an MTP done free of cost.In case of complications following the sterilization operation, including failure, I willaccept the compensation as per the existing provisions of the Government of IndiaFamily Planning Insurance Scheme as full and final settlement.If I/my wife get (s) pregnant after the failure of the sterilization operation and if Iam not able to get the foetus aborted within two weeks, then I will not be entitledto claim any compensation over and above the compensation offered under theFamily Planning Insurance Scheme from any court of law in this regard or any othercompensation for the upbringing of the child.I agree to come for follow-up visits to the hospital/institution/doctor/health facilityas instructed, failing which I shall be responsible for the consequences, if any.I understand that vasectomy does not result in immediate sterilization. *I agree tocome for semen analysis three months after the operation to confirm the success ofthe sterilization surgery (azoospermia), failing which I shall be responsible for theconsequences, if any.(*Applicable in cases of male sterilization)I have read the above information.# The above information has been read out and explained to me in my own language,and it has been explained to me that this form has the authority of a legal document.
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DR. (SMT.) M.S. JayalakshmiDeputy C
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