REQUEST FOR ULTRASOUND EXAMINA­TION

I understand that an ultrasound is a procedure that enables the clinician to view my pregnancy to determine the age of the fetus and look at other struc­tures in my uterus.  This is done with an instrument that sends sound waves through the amniotic fluid (water bag).

I understand that this ultrasound is being done only to determine the age of the fetus and no abnormalities of my pregnancy, fetus, or reproductive tract.  More extensive studies may be needed to diagnose specific conditions or abnormalities in the pregnancy.  If more extensive studies are required, I understand that I will be referred to a specialist for further testing.  I also understand there are limita­tions to all imaging techniques, and that no technique is 100% accurate or reliable. 

While there is no evidence at present to prove the negative effects of ultrasound on a developing fetus, I am aware there may be an unrecognized risk with long-term exposure in any procedure. 

I have read the above information and have had all my questions answered. 

I release Choices Women’s Center and its staff and employees from any liability arising out of or connected with this procedure, particularly regarding any abnor­malities of my pregnancy, fetus, or reproductive tract which have not been evaluated by this study. 

I hereby request that a staff person authorized by Choices Women’s Center perform an ultrasound screening on me for the sole purpose of determining the age of the fetus. 

I hereby give my permission to Choices Women’s Center employees and others authorized by them to use information in my medical record for statistical purposes, with the understanding that confidentiality will be maintained.

A new Arizona law requires your physician to perform an ultrasound on patients prior to performing an abortion, as well as perform auscultation of the fetal heart tones.  The law also requires your physician to offer you an opportunity to view the ultrasound image, listen to the fetal heartbeat, if it is audible, offer to provide you with an explanation of the ultrasound image, and offer to provide you with a picture of the ultrasound image.

The new law requires patients to indicate whether they opted to view the ultrasound image and hear the heartbeat of the fetus.  We will retain this form in your medical records. 

CERTIFICATION OF OPPORTUNITY TO VIEW ULTRASOUND IMAGE AND HEAR FETAL HEARTBEAT

 I, certify that, at least one hour prior to my abortion, I was given the opportunity to view the active ultrasound image and hear the heartbeat of the fetus if the heartbeat is audible.

Request for Medical Services

Before you give your consent, be sure you understand the information we have provided you. If you have any questions as you read, we will be happy to discuss them with you. Remember that your sent is entirely voluntary. You may ask for a copy of this consent form.

Place your initials after each statement to indicate that you have read, understand, and agree with the statement.

HIPAA Acknowledgement 

By signing, I acknowledge that I received a copy of my healthcare provider’s Notice of Privacy Practices (NPP).

You have a follow-up appointment already scheduled 14 days from taking the abortion pill.

This appointment will consist of a urine pregnancy test. You may also choose to do a pregnancy test at home and call us with any questions or concerns.

Medication Abortion Consent Form 

What is medication abortion?

A medication abortion uses two medicines to end your pregnancy.

-          Mifepristone is the first medicine – it starts the abortion process. Your pregnancy needs a hormone called progesterone to grow normally. Mifepristone blocks your body’s progesterone.

-          The second medicine, misoprostol, opens the opening to your uterus (cervix) and makes your uterus contract in order to expel or push out the pregnancy.

What are the benefits of the medication abortion?
It is a safe and effective way to end a pregnancy. It can be done in the privacy of your home and does not require a pelvic exam.

How well does medication abortion work?
Medication abortion works over 95% of the time. Medication abortion is more effective after nine weeks when two doses of misoprostol are used. 5% of people who use medication abortion will need further treatment to end the pregnancy or manage complications or side effects.

Purpose: I understand that the purpose of abortion is to terminate a pregnancy.

Risks of Medication Abortion: Medication abortion is safe, but there are risks with any medical procedure. I understand these risks may include: 

·         Continuing pregnancy: In some cases, the pregnancy does not end after taking the medications. Because misoprostol can cause birth defects, if this happens you may need to take more medicine or have a procedure (called a “D&C” or “aspiration abortion”) to complete the abortion.

·         Incomplete abortion: Some of the pregnancy tissue or the pregnancy may be left inside your uterus. This may lead to heavy bleeding, infection, or both. If this happens, you may need a procedure, other tests, or treatments.

·         Hemorrhage: You may have too much bleeding or bleed for too long. If this happens, we may recommend medicine, a procedure, or, rarely, a blood transfusion or surgery to remove the uterus (hysterectomy).

·         Infection: The infection rate from medication abortion is less than 1%. Antibiotics are used to treat the infection, and, rarely, a suction procedure.

·         Allergic reaction: While rare, some people are allergic to the medicines used.

·         Death: Death from medication abortion is very rare. The risk of death from childbirth is about ten times greater.

Side Effects of Medication Abortion: Side effects usually do not last long. They usually need little or no treatment. I understand the following: 

·         Cramping: This is normal and is supposed to happen. Cramping is usually worst when the pregnancy is passing. Milder cramps may last for a few days. If you are having pain in your belly that is unrelieved by pain medication more than 24 hours after taking misoprostol, please contact us 520-210-8300.

·         Bleeding: This is also normal and is part of the abortion process. Bleeding is usually heaviest when the pregnancy is passing. You should call us if you are soaking 2 pads an hour for more than 2 hours in a row. You may bleed or spot for 4 to 6 weeks after the abortion.

·         Fever/chills: The misoprostol can make you feel as if you have a fever. We recommend you do not take your temperature for the first 24 hours. Having a temperature of 99-100°F is okay. If you have a fever greater than 100.4°F more than 24 hours after taking the misoprostol, please call us 520-210-8300.

·         Other side effects: It is common to have diarrhea, nausea, vomiting, headache, dizziness, back pain, and tiredness. These should go away 24 hours after taking misoprostol. If you are still having these symptoms more than 24 hours after taking misoprostol, please contact us 520-210-8300. 

Options: I understand with pregnancy there are three options to think about - abortion, adoption, and parenting. I understand there are two ways to have an abortion, medication abortion, and an abortion procedure. I understand I can talk to the staff about all of these options to help make my decision. 

What else do I need to know?
It is important to follow up after a medication abortion to ensure that the abortion is complete and that you are doing well. You may have a follow-up with a blood test or ultrasound in a week, or you may have a phone follow-up after the abortion. Do not take a home pregnancy test until at least four to six weeks after your medication abortion, as the hormones that can cause a “positive” result may remain in your body for a long time. If your provider recommends follow-up with a home pregnancy test, please follow their instructions. If after taking the medications you have no bleeding or cramping, or you are still experiencing pregnancy symptoms, please call us right away.

What if I have concerns or questions?
I have been given the contact information, and I agree to get in touch if I have any questions or concerns. 

I have read and understand the information provided to me about medication abortion. 

All information I have provided is true and correct and I acknowledge that the provider and their staff have relied on such information.

I give my consent voluntarily. No one is forcing me to make this decision. I am aware that I may have a copy of this information at my request. 

All my questions have been answered to my satisfaction.

CERTIFICATION THAT ABORTION IS NOT BEING PERFORMED ON THE BASIS OF SEX, RACE, OR GENETIC DISORDER

I certify that my decision to have an abortion is not based on the sex, the race of the father, my own race, or a genetic disorder of the fetus. I further certify that the abortion is not being financed because of the sex, race, or genetic disorder of the fetus.

PATIENT AGREEMENT FORM 

Healthcare Providers: Counsel the patient on the risks of mifepristone. Both you and the patient must sign this form. 

Patient Agreement:
1.  I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my provider’s advice about when to take each drug and what to do in an emergency.

2.  I understand:

a.  I will take mifepristone on Day 1.

b.  My provider will either give me or prescribe for me the misoprostol tablets, which I will take 24 to 48 hours after I take mifepristone.

3.  My healthcare provider has talked with me about the risks, including:

•  heavy bleeding

•  infection

•  ectopic pregnancy (a pregnancy outside the womb)

4.  I will contact the clinic/office right away if in the days after treatment I have:

•  a fever of 100.4°F or higher that lasts for more than four hours

•  severe stomach area (abdominal) pain

•  heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)

•  stomach pain or discomfort, or I am “feeling sick,” including weakness, nausea, vomiting, or diarrhea, more than 24 hours after taking misoprostol

5.  My healthcare provider has told me that these symptoms could require emergency care. If I cannot reach the clinic or office right away my healthcare provider has told me who to call and what to do.

6.  I should follow up with my healthcare provider about 7 to 14 days after I take mifepristone to be sure that my pregnancy has ended and that I am well.

7.  I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use this treatment. If my pregnancy continues after treatment with mifepristone and misoprostol, I will talk with my provider about a surgical procedure to end my pregnancy.

8.  If I need a surgical procedure because the medicines did not end my pregnancy or to stop heavy bleeding, my healthcare provider has told me whether they will do the procedure or refer me to another healthcare provider who will.

9.  I have the MEDICATION GUIDE for mifepristone. I will take it with me if I visit an emergency room or a healthcare provider who did not give me mifepristone so that they will understand that I am having a medical abortion with mifepristone.

10.  My healthcare provider has answered all my questions.

REQUEST FOR FIRST TRIMESTER SURGICAL COMPLETION OF MEDICATION ABORTION WITH ASPIRATION CURETTAGE

Before you give your consent, be sure you understand the information we have given you. If you have any questions as you read, we will be happy to discuss them with you. Remember that your consent is entirely voluntary. You may request a copy of this form.
Place your initials after each statement to indicate that you have read, understand, and agree with the statement.                                                 

I understand that other risks include: