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Patient Forms

For your convenience, some necessary forms are available here so you can print and complete them prior to your office visit.
Printing the forms will require that you have Adobe Acrobat Reader installed on your computer.
  • Quinacrine Sterilization Informed Consent - 9 Pages (139 kb)
    This file must be read and signed prior to having the QS procedure. It contains information regarding the process, follow-up procedures, effectiveness, risks, advantages, disadvantages, and more.

  • Patient Physical & Medical History (21 kb)
    This file is a medical history form. Please can fill out as much as possible and bring with you to your office visit.

To open PDF files, your computer must have a Adobe Acrobat Reader intalled. You can get Acrobat Reader for free directly from Adobe by clicking on the link below.


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Testimonial on QS
"My comments on Quinacrine:
Quinacrine changed my life!
The procedure was essentially painless, affordable, and freeing!
I love my new lifestyle.
Thank you, Dr. Whitney!"
-B.H.
Read More Testimonials

See the QS Video


Read Dr. Whitney's Presentation at the F.I.G.O. Convention

The drwhitney.com web site is maintained by Randall B. Whitney, M.D. to provide information about QS.
DrWhitney.com  Quinacrine Non-Surgical Method of Voluntary Female Sterilization - Home
DrWhitney.com  Quinacrine Non-Surgical Method of Voluntary Female Sterilization - Home
Call for More Info at 800-810-9840