I have asked for and received information about sterilization from:

Chirag A Patel MD PhD at Northern California Vasectomy

 

When I first asked for the information, I was told that the decision to be sterilized is completely my own. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I understand that I can change my mind at any time.

I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO FATHER ANY (MORE) BIOLOGIC CHILDREN.

I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to father a child in the future. I have rejected these alternatives and chosen to be sterilized.

I understand that I will undergo an operation known as a

BILATERAL VASECTOMY

The discomforts, risks, and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction.

I understand that the operation will not be done until at least 3 days after I sign this form (30 days for patients using Medicaid/Medi-cal)

I am at least 18 years of age.

I hereby consent of my own free will to undergo an operation intended to sterilize me, to be performed by Chirag A Patel by a method called BILATERAL VASECTOMY

I am not under the influence of alcohol or other substances that affect my state of awareness.

I understand that I may have a witness of my choice present during the time my consent is obtained.

My consent expires 180 days from the date of my signature below. I have received a copy of this form.