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Get CA PM 330 1999-2024

I, on (Name of individual to be sterilized) Last / Mo First M. I. hereby consent of my own free will to be sterilized by by a (Doctor’s name) method called . (Name of procedure) My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: • • Representatives of the Department of Health and Human Services. Employees of programs or projects funded by that Department but only.

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