Family PACT

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General Consent for Birth Control        Department of Health Care Services Family PACT logo 

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: 
  • Pill
  • Patch
  • Ring
  • Shot
  • Implant
  • Diaphragm    
  • Spermicides
  • Sponge
  • 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 understand.
  • 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.
Revised 2017
OF4146 General Consent ENG