Get Wi Dhs F-01164 2008-2025

The Wisconsin Department of Health Services Form F-01164 is a consent form for sterilization. This guide will help users navigate and complete the form effectively while ensuring all necessary information is provided in a clear and organized manner.

Follow the steps to accurately complete the form online.

1. Press the ‘Get Form’ button to access the F-01164 online. This will open the form in your preferred document editor.
2. Begin by filling out the section titled ‘Statement of Person Obtaining Consent.’ Here, enter the name of the individual who is providing consent and ensure that all required details about their understanding of the procedure are included.
3. In the ‘Consent to Sterilization’ section, the person giving consent should clearly indicate their understanding of the nature of sterilization, including the permanence of the procedure and the benefits available to them regardless of their decision.
4. Ensure the individual signs and dates the form, confirming that they acknowledge the information provided and are voluntarily choosing to proceed with the sterilization.
5. Next, the ‘Physician’s Statement’ must be completed by the physician performing the procedure. They need to confirm the individual's age, competency, and provide details of the sterilization operation.
6. If applicable, fill out the ‘Interpreter’s Statement’ section if an interpreter was involved in explaining the consent to the individual. The interpreter should provide their signature and date.
7. At the end of the form, verify that all required sections are completed and sign the document where necessary. Once completed, users can save changes, download, print, or share the form.

Prepare your documents and fill out the WI DHS F-01164 online today.