Tubal Ligation Consent Form

Tubal Ligation Consent Form
Please review and complete this form to confirm your understanding and consent for the tubal ligation procedure.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Physician/Provider Name
Date of Scheduled Procedure
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you discussed alternative birth control options with your healthcare provider?
Please list any allergies or medical conditions we should be aware of:
Emergency Contact Name and Phone Number
By signing below, I confirm that I have read and understood the information provided above, have had the opportunity to ask questions, and voluntarily consent to undergo the tubal ligation procedure.
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