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| General Consent for Birth Control
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:
- Cervical Cap
- Condoms for Men
- Condoms for Women
- Intrauterine Contraception (IUC)
- Natural Family Planning
- Fertility Awareness Method
- Lactation Amenorrhea Method
- Sterilization for Men
- Sterilization for Women
- My Family PACT provider has explained how to use the method I have chosen in a way that
- I have been told how the method works to prevent pregnancy and how well it works for most
- 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: _________________________
© 2009 Department of Health Care Services, Office of Family Planning. All rights reserved.
OF4146 General Consent ENG