Surgical Abortion Consent printable pdf download

Whole Woman’s Health

Surgical Abortion Consent

Please initial each section as you read.

______ I have read, discussed, and understand the “ABORTION SERVICES INFORMATION”

packet that includes the “POST-OPERATIVE INSTRUCTIONS.”

_____ I take full responsibility for this decision and agree to medical and surgical procedures to

attempt to end my pregnancy. I agree to be treated by a licensed physician associated with

Whole Woman’s Health, Dr. __________________, and any Whole Woman’s Health agents

or employees.

_____ I agree to the doctor or the doctor’s designated assistant giving me pain relievers or

other medication the physician feels is necessary for my care.

I am allergic to:

_______________________________________________.

_____ I understand that the fetal tissue removed during the abortion will be disposed of,

following legal and health guidelines.

_____ Whole Woman’s Health has a training program for teaching licensed physicians surgical

abortion procedures. I agree to be treated by a licensed training physician associated with

Whole Woman’s Health, Dr. __________________. (Optional)

_____ I understand that when possible, I shall be treated for any resulting complications by

Whole Woman’s Health in the clinic at no extra charge to me. However, should hospitalization

be necessary, I understand that I will be responsible for any charges.

_____ I also understand that in the rare circumstances which might result in my

hospitalization, Whole Woman’s Health cannot be held responsible for any breech in

confidentiality. I realize that in emergencies, it is sometimes necessary to contact other family

members, particularly the parents of minors.

_____ I give my permission to Whole Woman’s Health to receive my medical records from any

health provider who treats me for a complication.

I have read and understand the alternatives, benefits, and risks associated with the abortion

procedure, including:

1. ALTERNATIVES: Women who are pregnant can decide to continue or end the

pregnancy and, depending on the outcome of the pregnancy, can then decide to parent

or place the child for adoption. Each option will have benefits and risks. You need to

consider your choices carefully to be able to make the best decision for yourself.

2. BENEFITS: Abortion, adoption, and parenting can each have benefits, depending

upon the individual, the timing of the pregnancy, and the situation. The benefits of

carrying to term or having an abortion can be different for each person.

3. RISKS: Abortion is a minor surgical procedure. Like any surgery, it is possible that a

problem could happen during or after your procedure and require treatment. It is

important to know about risks and include this information as part of your decision.

Possible risks include but are not limited to the following (initial each).

Revised 06/2013 ES

Reviewed 06/2013 AF/ES

Surgical Abortion Consent