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Get HHS-687 2010

NY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. STATEMENT OF PERSON OBTAINING CONSENT CONSENT TO STERILIZATION I have asked for and received information about sterilization from . When I first asked Doctor or Clinic for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose a.

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