General Consent for Birth Control

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When you sign this consent form, it means that:

Your Family PACT provider has informed you there are many different types of birth control.
You have discussed which birth control method is right for you.
Your Family PACT provider has told you about how to use your birth control method
safely and successfully.

Directions: Read each statement carefully. If you agree with the statements, sign you name on
the line below.

I understand that there are many birth control methods I could choose from. These include:

My Family PACT provider has explained how to use the method I have chosen in a way that
I understand.
I have been told how the method works to prevent pregnancy and how well it works for most
people.
I have been told about the benefits and risks of using this method. We have discussed any
health problems I may have.
I have talked with my Family PACT provider about any side effects there may be with using
this method. I understand that side effects are reactions and changes that could happen
because I use this method.
My Family PACT provider has told me about any complications for the method I have
chosen. I understand that complications are rare but serious health problems that could
happen. I have been told the warning signs of these complications.
I understand what to do if I want to stop using the method I have chosen.

Based on this information, I have freely chosen to use ________________________________
as my method of birth control. (name of method)

Signature: ___________________________________ Date: _________________________